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Physical examination remains an important part of cardiology practice because it facilitates the further investigation and treatment of those in whom heart disease is confirmed or suspected and helps to reassure those without a heart condition. Clinical signs can provide accurate, valuable diagnostic and prognostic information of great relevance to patients with most cardiac conditions particularly heart failure, coronary heart disease, valvular heart disease, and adults with congenital heart disease. This chapter reviews the most useful clinical signs in cardiology and discusses their relevance and accuracy expressed, wherever possible, as likelihood ratios; the reader should, however, be aware of the limitations of this sort of evidence-based approach because clinical signs should never be interpreted in isolation.

Objectives The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR). Background Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes. Methods The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs). Results A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 ± 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p Conclusions This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial.

The use of learning objects (LOs), small chunks of learning stored digitally and reused or referenced to support learning, was described as a promising approach to the creation of e-learning modules or programmes. In practice, however, the early enthusiasm has waned and the approach has not been widely adopted. It is argued that this was due, at least in part, to a neglect of the pedagogy and an emphasis on the technical aspects of interoperability and reusability. This article describes a practical approach to constructing a learning module using LOs where a commentary links LOs selected for inclusion in the programme. The commentary tells the story of the e-learning module and provides the learner with a context for an LO. It can be viewed as a 'personal learning assistant' that advises students about the management of their learning and relates the e-learning module to the overall learning outcomes for the curriculum. The commentary also allows the lecturer to comment on LOs selected for inclusion in the programme which otherwise might have to be adapted or excluded when the programme was constructed. The use of a commentary to link and introduce LOs has been successfully adopted in the development of e-learning programmes. Teachers are encouraged to consider the approach and to look again at the use of LOs to create e-learning resources.

Objective: To investigate the effect of distance between home and acute hospital on mortality outcome of patients experiencing an incident myocardial infarction (MI). Design: Cohort study using a record linkage database. Setting: Tayside, Scotland, UK. Patients: 10 541 patients with incident acute MI between 1994 and 2003 were identified from Tayside hospital discharge data and from death certification data. Main outcome measures: MI mortality in the community, all-cause mortality in hospital and all-cause mortality during follow-up. Results: 4133 subjects died following incident MI in the community (that is, were not hospitalised), 6408 patients survived to be hospitalised and 1010 of these (15.8%) died in hospital. Of 5398 discharged from hospital, 1907 (35.3%) died during a median of 3.2 years of follow-up. After adjustment for rurality and other known risk factors, distance between home and admitting hospital was significantly associated with increased mortality both before hospital admission (adjusted odds ratio (OR), 2.05, 95% CI 1.00 to 4.21 for >9 miles and 1.46, 1.09 to 1.95 for 3–9 miles when compared to

Many studies rely on self-reported smoking status. We hypothesized that patients with acute coronary syndrome (ACS), a smoking-related condition, would be more prone to misclassify themselves as ex-smokers, because of pressure to quit. We compared patients admitted with ACS with a general population survey conducted in the same country at a similar time. We determined whether ACS patients who classified themselves as ex-smokers (n = 635) were more likely to have cotinine levels suggestive of smoking deception than self-reported ex-smokers in the general population (n = 289). On univariate analysis, the percentage of smoking deceivers was similar among ACS patients and the general population (11% vs. 12%, p = .530). Following adjustment for age, sex and exposure to environmental tobacco smoke, ACS patients were significantly more likely to misclassify themselves (adjusted OR = 14.06, 95% CI 2.13-93.01, p = .006). There was an interaction with age whereby the probability of misclassification fell significantly with increasing age in the ACS group (adjusted OR = 0.95, 95% CI 0.93-0.97, p

The Losartan Intervention For Endpoint Reduction (LIFE) study demonstrated a clear mortality benefit in treating hypertensive patients with electrocardiogram (ECG) evidence of left ventricular hypertrophy (LVH) with losartan rather than atenolol. Previous studies have also shown that identifying and treating echo LVH is associated with prognostic benefits in hypertensive subjects, and is independent of the presence of ECG LVH. We sought to determine how many cases of echo LVH would be missed by applying the ECG criteria for LVH used in the LIFE study.A prospective study of 219 patients with type 2 diabetes recruited from the hospital diabetic clinic.Fifteen ECG criteria were assessed on each subject and compared with the presence or absence of LVH on echocardiography.All the proposed ECG criteria are poor at identifying echo LVH in people with diabetes.Using ECG LVH to select patients for angiotensin receptor blockade would lead to many diabetics with echo LVH missing out on the benefits of treatment. This assumes that the benefits seen in the LIFE study would also occur if the LIFE strategy were extended to echo LVH patients as well as to ECG LVH patients.

Context At a time of significant changes in medical education world-wide, the international dimensions and global issues relating to the application of new learning technologies have been recognised. Objective The aim of this paper is to describe the adoption and integration within the curriculum in one United Kingdom (UK) medical school of ‘Harvey’, the Cardiology Patient Simulator, and the UMedic multimedia computer-based cardiology curriculum ‐ resources developed in a medical school in the USA. Participants The integration of the resources into the curriculum is described by 3 teachers actively involved in the cardiology curriculum of the UK medical school and 3 teachers associated with the development of resources in the USA. Aspects considered The review considers the adoption of Harvey and UMedic in the UK in programmes in relation to: curricular issues, training needs, learning outcomes, curriculum content and sequences of content, educational strategies, teaching and learning methods, assessment, communication about the curriculum and management of the curriculum. Conclusions Learning resources, in the form of simulators and computer-based learning modules, developed in one country can be successfully adopted and implemented in another. Facets that facilitated the adoption included close liaison between the developers of the resources in the USA and the implementers in the UK, and careful and systematic planning including in-depth integration of the simulation-based resources into the required curriculum rather than their relegation to a peripheral ad hoc position. The successful use of simulators such as Harvey requires the presence of a ‘champion’, a clinician educator and a supporting administrative staff who ensure the simulator’s appropriate use.

To evaluate a system of prehospital thrombolysis, delivered by paramedics, in meeting the national service framework's targets for the management of acute myocardial infarction.Prospective observational cohort study comparing patients with suspected acute myocardial infarction considered for thrombolysis in the prehospital environment with patients treated in hospital.The catchment area of a large teaching hospital, including urban and rural areas.201 patients presenting concurrently over a 12 month period who had changes to the electrocardiogram that were diagnostic of acute myocardial infarction or who received thrombolysis for suspected acute myocardial infarction.Time from first medical contact to initiation of thrombolysis (call to needle time), number of patients given thrombolysis appropriately, and all cause mortality in hospital.The median call to needle time for patients treated before arriving in hospital (n=28) was 52 (95% confidence interval 41 to 62) minutes. Patients from similar rural areas who were treated in hospital (n=43) had a median time of 125 (104 to 140) minutes. This represents a median time saved of 73 minutes (P0.001). Sixty minutes after medical contact 64% of patients (18/28) treated before arrival in hospital had received thrombolysis; this compares with 4% of patients (2/43) in a cohort from similar areas. Median call to needle time for patients from urban areas (n=107) was 80 (78 to 93) minutes. Myocardial infarction was confirmed in 89% of patients (25/28) who had received prehospital thrombolysis; this compares with 92% (138/150) in the two groups of patients receiving thrombolysis in hospital.Thrombolysis delivered by paramedics with support from the base hospital can meet the national targets for early thrombolysis. The system has been shown to work well and can be introduced without delay.

The Sphygmocor system purports to be able to assess ascending aortic blood pressure using a transfer function. It has been shown to be accurate when data obtained invasively are used, but has not been tested prospectively using data obtained non-invasively.To investigate the accuracy of this equipment when measurements are obtained non-invasively, as would normally be the case in the clinic setting.The study was observational. Ascending aortic pressure measurements were taken simultaneously with radial artery pressure wave recordings for estimation of ascending aortic blood pressure, in 28 patients undergoing diagnostic cardiac catheterization.The transfer function in the Sphygmocor system significantly underestimated invasively measured systolic blood pressure [mean -7.23 +/- 10.07 mmHg; 95% confidence interval (CI) -3.3 to -11.14 mmHg, P = 0.001] and significantly overestimated invasively measured diastolic blood pressure (mean 12.20 +/- 7.14 mmHg; 95% CI 9.43 to 14.97 mmHg, P0.001). Oscillometrically measured brachial systolic blood pressure was not significantly different from that measured invasively in the ascending aorta (mean 3.36 +/- 10.47 mmHg; 95% CI -0.69 to 7.43 mmHg, P = 0.1), but oscillometric measurement of brachial diastolic blood pressure gave a significant overestimation of that measured invasively (mean 11.70 +/- 7.18 mmHg; 95% CI 8.91 to 14.49 mmHg, P0.001). CONCLUSIONS The transfer function in the Sphygmocor system is no better at estimating ascending aortic blood pressure than are standard peripheral blood pressure measurements. It may be necessary to derive a new transfer system that is based on data that are acquired entirely non-invasively.

OBJECTIVE: Glutamine enhances recovery from acute normothermic ischemia in isolated rat heart by a dose-dependent effect (Khogali et al. J Mol Cell Cardiol 1998;30:819). We compared the cardioprotective effects of equimolar concentrations of glutamine, glutamate, and aspartate in isolated rat heart. We also explored the potential cardioprotective effects of glutamine in patients with chronic stable angina. METHODS: The isolated perfused working rat heart was subjected to ischemia, followed by reperfusion with or without an amino acid (2.5 mM). Patients with chronic stable angina received a single oral dose of glutamine (80 mg/kg) or placebo in a double-blind, random fashion 40 min before a standard Bruce exercise test. RESULTS: Postischemic reperfusion of isolated rat heart with glutamine (but not with glutamate or aspartate) resulted in full recovery of cardiac output. Only glutamine prevented the decrease in the myocardiol ratio between adenosine triphosphate to adenosine diphosphate and significantly enhanced the myocardial ratio of reduced to oxidized glutathione. A single oral dose of glutamine given to patients with chronic stable angina significantly increased plasma glutamine concentration from 419 to 649 μM and delayed time to onset of more than 1.0 mm of ST segment depression on the ECG by 38 s. CONCLUSION: Glutamine may be cardioprotective in patients with coronary heart disease.

Introduction Delay to presentation with symptoms of acute coronary syndrome (ACS) is common meaning many fail to achieve optimal benefit from treatments. Interventions have had variable success in reducing delay. Evidence suggests inclusion of behaviour change techniques (BCTs) may improve effectiveness of interventions but this has not yet been systematically evaluated. Data from other time-critical conditions may be relevant. Methods and analysis A systematic review will be undertaken to identify which BCTs are associated with effective interventions to reduce patient delay (or prompt rapid help-seeking) among people with time-critical conditions (eg, chest pain, ACS, lumps, stroke, cancer and meningitis). A systematic search of a wide range of databases (including Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycInfo) and grey literature will be undertaken to identify all relevant intervention studies (randomised controlled trials, controlled clinical trials and cohort studies). Two independent reviewers will screen abstracts to identify relevant studies, apply inclusion criteria to full papers, assess methodological quality and extract data. Primary outcome measure Change in patient decision time BCTs reported in each of the included studies will be categorised and presented according to the latest reliable taxonomy. Results of included studies will be synthesised, exploring relationships between inclusion of each BCT and effectiveness of the overall intervention. Where possible, means and SDs for differences in delay time will be calculated and combined within meta-analyses to derive a standardised mean difference and 95% CI. Analysis of (1) all time-critical and (2) ACS-only interventions will be undertaken. Ethics and dissemination No ethical issues are anticipated. Results will be submitted for publication in a relevant peer-reviewed journal.

OBJECTIVES The study was designed to comprehensively evaluate the circadian effects of aldosterone blockade on autonomic tone and QT dispersion in chronic heart failure (CHF). BACKGROUND Spironolactone therapy given in addition to angiotensin-converting enzyme inhibitors improved survival in CHF, but the mechanism of its benefit is uncertain. Experimental evidence suggests that aldosterone may have detrimental effects on the autonomic nervous system, especially during the morning hours. METHODS Twenty-eight patients with New York Heart Association class II to IV CHF received spironolactone 50 mg daily and placebo for four weeks each in a double-blind crossover fashion. After each treatment phase, a full circadian assessment was undertaken of spironolactone's autonomic effects. The assessment included monitoring heart rate, QT dispersion, continuous Holter recordings, heart rate variability (HRV) and norepinephrine kinetics. RESULTS Spironolactone significantly reduced all indices of QT dispersion. The reductions in QTcmax, QTd and QTcd were greatest at 6 AM. In addition, spironolactone had favorable autonomic effects, which were limited to the morning (6-10 AM), including heart rate reduction and an improvement in HRV. CONCLUSIONS Spironolactone reduced heart rate and improved HRV and QT dispersion in CHF. Its effects were particularly prominent during the morning hours.

Objective: To determine whether low serum cortisol concentrations are associated with adverse prognosis in patients with acute myocardial infarction. Low serum cortisol concentrations have been associated with adverse prognosis in critical illness of diverse etiology. Design: Nested case-control study. Setting: Prospective cohort study of consecutive patients admitted with acute myocardial infarction to nine Scottish hospitals. Patients: A total of 100 patients who survived 30 days (controls) and 100 patients who died within 30 days (cases). Measurements and Main Results: Admission cortisol concentrations were lower in patients who died than those who survived (median, 1189 nmol/L vs. 1355 nmol/L; p < .001). A cortisol concentration in the bottom quartile (

Aims—To determine the sensitivity and specificity of each ICD9 code for a diagnosis of definite or possible myocardial infarction (MI) from the perspective of the Myocardial Infarction Causality Study (MICA) and to use these data to estimate the likely number of MICA cases in Scotland that would be undetected were these codes omitted from the study. Setting—Women resident and registered with general practitioners in the Tayside region of Scotland between October 1993 and October 1995. Method—All SMR1 records of Tayside hospitalizations containing ICD9 (International Classification of Diseases, ninth revision) codes for myocardial infarction (410) or possible myocardial infarction (411, 412, 413, 414, 427.4, 427.5, 786.5) were identified for women aged between 16 and 44 years between 1 October 1993 and 15 October 1995. Original case records were sought and each episode abstracted using a predefined form. Records were independently scrutinized by two consultant cardiologists blinded to the SMR1 code. Cases were categorized as definite MI, possible MI or unlikely MI. Where there was disagreement between the two cardiologists, the profiles for such events were examined by a third cardiologist who acted as the final adjudicator. The adjudicator's verdict was, in this study, considered dominant. The sensitivity, specificity and positive predictive value of each ICD9 code was determined. Results—Two hundred and fifty-three women fulfilled the SMR1 search criteria. Case records of 204 (81%) were retrieved but four case records contained no data on the admission of interest and were classified as invalid. Forty-six of the 200 remaining patients were ineligible for the MICA study leaving 154 records for evaluation. There were 12 patients who had a discharge code for MI (ICD9 410). Of these, 11 were judged as a definite MI by both cardiologists. One event (discharge code ICD9 410) was judged as ‘possible’ by one cardiologist and ‘unlikely’ by the other. The adjudicator subsequently judged this event as ‘definite’. Another six events were subsequently judged as ‘possible’. Thus, after adjudication, 12 cases of definite MI and six cases of ‘possible’ MI were identified. The sensitivity and specificity of ICD9 code 410 was 67% and 100% respectively. The positive predictive value was 100%. The sensitivity of code 411 was 5·6%. The specificity was 99% and the positive predictive value was 50%. Code 413 had a sensitivity of 5·6% with a specificity of 94% and a positive predictive value of 9·1%. Code 414 also had a sensitivity of 5·6%. The specificity was 86% and the positive predictive value was 4·5%. Code 786·5 had a sensitivity of 17%, a specificity of 23% and a positive predictive value of 2·5%. Code 427·5 failed to identify any definite or possible cases. Conclusions—In the MICA Study, ICD9 code 410 was found to be the most robust. All 12 patients judged to have had a definite MI had the appropriate discharge code (ICD9 410). The six patients judged to have had a possible MI all had discharge codes other than that for MI (410). However, identifying these six patients required the validation of a further 160 events—giving a combined sensitivity of 33%, a specificity of 0% and a positive predictive value of only 3·8%. The use of ICD9 codes 411, 413, 414, 427·5 and 786·5 must, therefore, only be employed when circumstances fully justify the additional workload. Copyright © 1998 John Wiley & Sons, Ltd.

We present a case of vertical gaze palsy in a 13-year-old girl caused by underlying infective endocarditis, secondary to an infected navel piercing. This case illustrates that infective endocarditis does not always present with classic signs. J Pediatr Ophthalmol Strabismus 2006;43:41-43. AUTHORS The authors are from Ninewells Hospital, Dundee, Scotland. Originally submitted March 30, 2004. Accepted for publication November 19, 2004. Address reprint requests to Dr. Andrew Ferguson, Department of Ophthalmology, Ninewells Hospital, Dundee DD1 9SY, Scotland. Presented in part at the Annual Meeting of the Scottish Ophthalmological Club; October 3, 2003; Erskine, Scotland.

Aims Resting plasma levels of atrial natriuretic peptide and B-type natriuretic peptide rise with left ventricular dysfunction, but little is known about effects of cardiac ischaemia on atrial natriuretic peptide and B-type natriuretic peptide levels during exercise. We investigated exercise levels of atrial natriuretic peptide and B-type natriuretic peptide in patients with suspected angina to determine whether these measurements could improve non-invasive assessment of coronary disease severity. Methods and results One hundred patients performed an exercise test (Bruce protocol) within 2 weeks of coronary angiography. Plasma levels of atrial natriuretic peptide and B-type natriuretic peptide were measured at rest and at peak exercise. Multivariate regression analysis was used to assess effects of age, sex, coronary anatomy, exercise time and ventricular function on atrial natriuretic peptide and B-type natriuretic peptide levels. Increasing age and female sex were significantly associated with higher resting atrial natriuretic peptide levels; age alone was associated with higher exercise atrial natriuretic peptide levels. As expected, left ventricular end-diastolic pressure and disease of left anterior descending and circumflex coronary arteries were associated with increased resting B-type natriuretic peptide levels. However, the usual rise in B-type natriuretic peptide levels during exercise was independently reduced by disease of the right coronary artery. Conclusion This paradoxical effect of right coronary artery disease limits the value of natriuretic peptide measurements as predictors of coronary disease severity. Impaired release of B-type natriuretic peptide may reduce exercise tolerance in patients with right coronary artery disease.

Background Experimental models suggest that brain natriuretic peptide (BNP) can modify left ventricular diastolic performance. The aim of this study was to evaluate the effects of BNP on resting and exercise hemodynamics and neurohormones in patients with isolated diastolic heart failure. Methods and Results Six patients with isolated diastolic heart failure were studied. After baseline hemodynamic measurements were obtained with use of thermistor-tipped pulmonary artery catheters, patients were randomized to receive infusion of BNP or placebo in a single-blind, crossover study. Hemodynamic and neurohormonal parameters were measured at rest after 30 minutes of infusion and during incremental supine bicycle exercise. BNP did not significantly affect resting hemodynamics but attenuated the rise in both pulmonary capillary wedge pressure (placebo, 23±2 mm Hg; BNP, 16±2 mm Hg; P P P Conclusions BNP infusion causes beneficial hemodynamic and neurohormonal effects during exercise in patients with isolated diastolic heart failure.

Aims The presence of pulmonary hypertension (PH) in left ventricular systolic dysfunction (LVSD) and symptomatic heart failure is an ominous sign. There are insufficient data regarding the risk conferred by increasing severity of PH in patients with heart failure. Methods and results We performed a record linkage study in Tayside, Scotland (population ∼400 000) utilizing the Tayside echocardiogram database (>50 000 echocardiograms) maintained by the Health Informatics Centre (HIC). Data sets from the HIC include mortality data, cardiovascular medications, and other healthcare activities linked anonymously by the community health index (CHI) number. Patients were included in the analysis if they had LVSD, had a valid right ventricular systolic pressure (RVSP) measurement, and had a loop diuretic prescription (provided not more than 1 year prior to echocardiogram). A Cox proportional hazard model was used to examine the effects of RVSP on all-cause mortality. A total of 1612 patients [mean age, 75.2 ± 10.9 (SD) years; 57.4% male] met the entry criteria. Mean RVSP for the cohort was 44.9 ± 13.1 mmHg and mean follow-up was 2.8 ± 2.5 years. For each 5 mmHg stepwise increase in RVSP, after adjustment for confounding factors including the degree of LVSD and the presence of chronic obstructive pulmonary disease, the hazard ratio (HR) for all-cause mortality was 1.06 (1.03–1.08, P < 0.001). Conclusions Pulmonary hypertension predicted all-cause mortality in a heterogeneous group of patients with heart failure. Each 5 mmHg rise in RVSP was associated with a 6% increased risk of death.

Background Right ventricular apical pacing can cause dyssynchronous activation of the ventricles, increase sympathetic activation, cause abnormalities in myocardial perfusion, worsen cardiac output and endothelial function, and may be associated with adverse cardiovascular effects. The use of rennin–angiotensin system blockers (RASBs) may be beneficial in counteracting these potentially harmful effects of right ventricular pacing. Objective To explore the impact of RASB use on the outcome in patients with right ventricular pacemakers implanted for complete atrioventricular (AV) block. Methods Patients implanted with right ventricular pacemakers for complete AV block between 1994 and 2009 were identified from the Tayside Pacing Registry. Cox proportional hazards model was used to assess differences in all-cause mortality and congestive heart failure hospitalizations for those receiving RASB during follow-up, adjusted for confounding variables. We also performed 2 sensitivity analyses—a propensity score–matched analysis and time-dependent analyses—to minimize bias. Results Eight hundred twenty patients (57% men; median age 73 years; range 22–103 years) received pacemakers for complete AV block between 1994 and 2008 (54% dual-chamber pacemaker and 46% ventricular demand pacemaker). Two hundred seventy-eight (34%) patients had received RASBs. Mean follow-up was 4.9 ± 4.6 years, with 540 (65%) deaths. RASB use was independently associated with significantly reduced mortality (adjusted hazard ratio 0.67; 95% confidence interval 0.47–0.94; P = .017) and reduced heart failure hospitalization (adjusted hazard ratio 0.42; 95% confidence interval 0.17–0.92; P Conclusions This study suggests that RASBs may confer outcome benefits in patients with right ventricular pacemakers implanted for complete AV block.

The aim of this study was to investigate the effect of renin-angiotensin system blockade on outcomes in patients with aortic regurgitation (AR).Angiotensin-converting enzyme (ACE) inhibitors have the potential to reduce afterload, blunt left ventricular wall stress, and limit left ventricular dilation and hypertrophy. However, long-term studies have yielded inconsistent results, and very few have assessed clinical outcomes.The Health Informatics Centre dispensed prescription and morbidity and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database. Patients diagnosed with at least moderate AR from 1993 to 2008 were identified. Cox regression analysis was used to assess differences in all-cause mortality and cardiovascular (CV) and AR events (heart failure hospitalizations, heart failure deaths, or aortic valve replacement) between those treated with and without ACE inhibitors or angiotensin receptor blockers (ARBs).A total of 2,266 subjects with AR (median age 74 years; interquartile range: 64 to 81 years) were studied, with a mean follow-up period of 4.4 ± 3.7 years. Seven hundred and five patients (31%) received ACE inhibitor or ARB therapy. There were 582 all-cause deaths (25.7%). Patients treated with ACE inhibitors or ARBs had significantly lower all-cause mortality and fewer CV and AR events, with adjusted hazard ratios of 0.56 (95% confidence interval [CI]: 0.64 to 0.89; p0.01) for all-cause mortality, 0.77 (95% CI: 0.67 to 0.89; p0.01) for CV events, and 0.68 (95% CI: 0.54 to 0.87; p0.01) for AR events.This large retrospective study shows that the prescription of ACE inhibitors or ARBs in patients with moderate to severe AR was associated with significantly reduced all-cause mortality and CV and AR events. These data need to be confirmed by a prospective randomized controlled outcome trial.

To evaluate the relationship between sudden cardiac death, ventricular arrhythmias and left ventricular hypertrophy in patients with hypertension.Epidemiological studies assessing the importance of left ventricular hypertrophy as a risk factor for sudden cardiac death, studies assessing the prevalence of arrhythmias in left ventricular hypertrophy and studies assessing whether there is an electrophysiological substrate in the hypertrophied myocardium for ventricular dysrhythmias.Current evidence indicates that left ventricular hypertrophy is a risk factor for sudden cardiac death and that ventricular arrhythmias are more prevalent in hypertensive patients with than in those without left ventricular hypertrophy. However, there is a lack of evidence that these dysrhythmias are important as an underlying mechanism for sudden cardiac death, and there is no clear evidence that the hypertrophied myocardium is, itself, an arrhythmogenic substrate for malignant ventricular dysrhythmias. One possible mechanism for sudden cardiac death is myocardial ischaemia, either as a consequence of associated coronary disease or due to left ventricular hypertrophy, but this remains unproved.There is currently no evidence that the ventricular ectopic activity seen in patients with hypertensive left ventricular hypertrophy is a marker for sudden cardiac death. Clarification of the mechanisms involved in sudden cardiac death will help in selecting appropriate preventive and therapeutic strategies for these patients.

ObjectivesThe purpose of this study was to investigate the impact of renin-angiotensin system blockade therapy on outcomes in aortic stenosis (AS).BackgroundAngiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are perceived to be relatively contraindicated in AS. However, inhibitors of the renin-angiotensin system may be beneficial in AS through their cardioprotective and beneficial effects on left ventricular remodeling.MethodsThe Health Informatics dispensed prescribing, morbidity, and mortality database for the population of Tayside, Scotland, was linked through a unique patient identifier to the Tayside echocardiography database (>110,000 scans). Patients with a diagnosis of AS from 1993 to 2008 were identified. Cox regression model (adjusted for confounding variables) and propensity score analysis were used to assess the impact of ACEIs or ARBs on all-cause mortality and cardiovascular (CV) events (CV death or hospitalizations).ResultsA total of 2,117 patients with AS (mean age 73 ± 12 years, 46% men) were identified and 699 (33%) were on ACEI or ARB therapy. Over a mean follow-up of 4.2 years, there were 1,087 (51%) all-cause deaths and 1,018 (48%) CV events. Those treated with ACEIs or ARBs had a significantly lower all-cause mortality with an adjusted hazard ratio of 0.76 (95% confidence interval: 0.62 to 0.92, p < 0.0001) and fewer CV events with an adjusted hazard ratio of 0.77 (95% confidence interval: 0.65 to 0.92, p < 0.0001). The outcome benefits of ACEIs/ARBs were further supported by propensity score analysis.ConclusionsThis large observational study suggests that ACEI/ARB therapy is associated with an improved survival and a lower risk of CV events in patients with AS.

OBJECTIVE--To assess the prevalence of symptomatic and silent myocardial ischaemia in patients with hypertensive left ventricular hypertrophy. DESIGN--Cross sectional study. SETTING--University department of medical cardiology. PATIENTS--90 patients (68 men and 22 women; mean age 57 (range 25 to 79)) with left ventricular hypertrophy due to essential hypertension. INTERVENTIONS--48 hour ambulatory ST segment monitoring (all patients), exercise electrocardiography (n = 79), stress thallium scintigraphy (n = 80), coronary arteriography (n = 35). RESULTS--43 patients had at least one episode of ST segment depression on ambulatory electrocardiographic monitoring. The median number of episodes was 16 (range 1 to 84) with a median duration of 8.6 (range 2 to 17) min. Over 90% of these episodes were clinically silent. 26 patients had positive exercise electrocardiography and 48 patients had reversible thallium perfusion defects despite chest pain during exercise in only five patients. 18 of the 35 patients who had coronary arteriography had important coronary artery disease. Seven of these patients gave no history of chest pain. CONCLUSIONS--Symptomatic and silent myocardial ischaemia are common in hypertensive patients with left ventricular hypertrophy, even in the absence of epicardial coronary artery disease.

Hypertensive patients with the electrocardiographic (ECG) pattern of left ventricular (LV) hypertrophy and strain are at increased risk of sudden death. It has been suggested that ventricular arrhythmias may be responsible. The prevalence and significance of ventricular arrhythmias was therefore studied in 90 hypertensive patients with LV hypertrophy and strain by undertaking 48-hour ambulatory ECG monitoring, ECG signal-averaging and programmed ventricular stimulation. Complex ventricular ectopic activity (Lown grade greater than or equal to 3) was detected in 59 patients (66%). Eleven patients (12%) had episodes of nonsustained ventricular tachycardia. There were no sustained arrhythmias either on ambulatory ECG monitoring or induced by programmed ventricular stimulation. Only 1 patient had ventricular late potentials recorded by the signal-averaged electrocardiogram. Therefore, there was little to suggest an underlying arrhythmogenic substrate in these patients. In conclusion, whereas ventricular arrhythmias occur often in patients with LV hypertrophy associated with systemic hypertension, their significance, if any, remains to be established.

Objective: To determine whether exposure to secondhand smoke is associated with early prognosis following acute coronary syndrome. Design, setting and participants: We interviewed consecutive patients admitted to nine Scottish hospitals over 23 months. Information was obtained, via questionnaire, on age, sex, smoking status, postcode of residence and admission serum cotinine concentration was measured. Follow-up data were obtained from routine hospital admission and death databases. Results: Of the 5815 participants, 1261 were never-smokers. Within 30 days, 50 (4%) had died and 35 (3%) had a non-fatal myocardial infarction. All-cause deaths increased from 10 (2.1%) in those with cotinine ⩽0.1 ng/ml to 22 (7.5%) in those with cotinine >0.9 ng/ml (χ 2 test for trend p 0.9 ng/ml: adjusted OR 4.80, 95% CI 1.95 to 11.83, p = 0.003). The same dose response was observed for cardiovascular deaths and death or myocardial infarction. Conclusions: Secondhand smoke exposure is associated with worse early prognosis following acute coronary syndrome. Non-smokers need to be protected from the harmful effects of secondhand smoke.

The Doppler echocardiographic indexes of the tricuspid and mitral valves were assessed in 74 normal subjects (35 women and 39 men, mean age 45 years). A reproducibility study was also performed to examine the various sources of technical and biological variability. There were significantly higher peak early and late flow velocities across the mitral valve than across the tricuspid valve (0.67 ± 0.13 and 0.47 ± 0.12 vs 0.51 ± 0.08 and 0.35 ± 0.09 m·s−1, respectively; all p < 0.0001). There was no significant difference between the early:late (E:A) velocity ratios of the 2 valves (1.65 ± 0.73 vs 1.75 ± 0.67, p < 0.01). There was a steeper mitral early deceleration slope (−3.59 ± 1.07 vs −2.95 ± 0.91 m·s−2) but no significant difference in pressure half-times across the 2 valves (47 ± 7 vs 51 ± 12 ms, p < 0.1). No influence of gender or body surface area could be demonstrated. There was a weak but significant relation between mitral peak early, peak atrial velocity and E:A ratio and age (r = −0.39, p < 0.001, r = 0.23, p < 0.01, and r = −0.245, p < 0.01, respectively). There was no significant correlation between any of the tricuspid flow parameters and age. Respiration caused pronounced variability in the tricuspid Doppler indexes and all tricuspid flows were sampled and analyzed only during inspiration. The intra- and interobserver variabilities were small for all of the Doppler indexes measured, but the day-to-day variability was quite significant especially for the pressure halftime, deceleration and acceleration slope values. The present study documents in detail the normal Doppler flow characteristics of the tricuspid valve and compares them with the normal mitral flow parameters in the same subject.

Previous studies have suggested a reduction in the total number of hospital admissions for acute coronary syndrome after the enactment of legislation banning smoking in public places. However, it is unknown whether the reduction in admissions involved nonsmokers, smokers, or both.Since the end of March 2006, smoking has been prohibited by law in all enclosed public places throughout Scotland. We collected information prospectively on smoking status and exposure to secondhand smoke based on questionnaires and biochemical findings from all patients admitted with acute coronary syndrome to nine Scottish hospitals during the 10-month period preceding the passage of the legislation and during the same period the next year. These hospitals accounted for 64% of admissions for acute coronary syndrome in Scotland, which has a population of 5.1 million.Overall, the number of admissions for acute coronary syndrome decreased from 3235 to 2684--a 17% reduction (95% confidence interval, 16 to 18)--as compared with a 4% reduction in England (which has no such legislation) during the same period and a mean annual decrease of 3% (maximum decrease, 9%) in Scotland during the decade preceding the study. The reduction in the number of admissions was not due to an increase in the number of deaths of patients with acute coronary syndrome who were not admitted to the hospital; this latter number decreased by 6%. There was a 14% reduction in the number of admissions for acute coronary syndrome among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. Persons who had never smoked reported a decrease in the weekly duration of exposure to secondhand smoke (P0.001 by the chi-square test for trend) that was confirmed by a decrease in their geometric mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P0.001 by the t-test).The number of admissions for acute coronary syndrome decreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved nonsmokers. However, fewer admissions among smokers also contributed to the overall reduction.

To examine whether endogenous aldosterone can cause either arrhythmias (and some of their underlying mechanisms) or endothelial dysfunction in patients with coronary artery disease (CAD) but without heart failure.Aldosterone blockade has been shown to reduce the incidence of sudden death in patients with heart failure. This could be caused by a reduction in arrhythmias or in coronary events. Whether either effect also occurs in other cardiac patients without heart failure is currently unknown.We performed a randomized, placebo-controlled, double-blind crossover study on 98 patients with CAD but without heart failure on standard therapy, comparing 12.5-50 mg/day spironolactone (3 months) with placebo. Endothelial function was assessed by bilateral forearm venous occlusion plethysmography. Ventricular extrasystoles, procollagen III N-terminal peptide (PIIINP) and QT interval length were used to represent arrhythmias and their determinants.Spironolactone produced a highly significant 75% reduction in ventricular extrasystoles (median 192, range 48-744) on placebo compared with spironolactone (median 48, range 19.2-288, P0.003). Spironolactone also decreased the QT interval from a mean of 440 +/- 28 to a mean of 425 +/- 25 (P0.001) and a collagen marker (PIIINP) from a mean of 3.6 +/- 0.9 to a mean of 3.0 +/- 0.8 (P0.001), but did not significantly change endothelial dysfunction or heart rate variability.These results suggest that despite conventional therapy, endogenous aldosterone can be an arrhythmogenic influence in patients with CAD, but without heart failure. The possible mechanisms are that aldosterone promotes myocardial fibrosis and lengthens the QTc interval as well as decreasing potassium in CAD patients without heart failure.

Background: Diagnosing suspected left ventricular systolic dysfunction (LVSD) in the community is a challenge for GPs. We developed and validated a clinical prediction rule (CPR) for LVSD based on history, examination and electrocardiogram (ECG). Methods: Prospective cohort studies of 458 symptomatic patients (derivation cohort) and 535 patients (validation cohort) in 26 general practices in Tayside and Fife, Scotland. All patients underwent a structured clinical examination and ECG and the ‘reference standard’ investigation of echocardiography to establish the presence of LVSD. Results: Four elements from the clinical history and examination were all independently associated with LVSD—male sex [adjusted odds ratio (OR) 2.5; 95% CI 1.1, 5.0], presence of orthopnoea (OR 5.4; 1.9, 13.8) history of myocardial infarction (OR 5.6; 2.3, 13.6) and elevated jugular venous pulsations (OR 15.1; 4.6, 49.3). Addition of ECG (OR 20.6; 2.7, 158.6) provides important diagnostic information in terms of probability of LVSD. A CPR based on the presence or absence of these five elements will generate probabilities ranging from 1% to 97% for LVSD when applied to an individual patient. In the validation cohort, the model under-predicted the probability of LVSD, particularly at lower levels of expected risk, reflecting differences in the risk-factor profiles of the derivation and validation cohorts. Conclusions: The derived CPR provides quantitative estimates of post-test probability for LVSD. This rule requires further validation in other populations and settings because of the difficulties encountered in the validation cohort.

Diagnostic echocardiography has poor access for patients with suspected heart failure. Pre-echocardiography screening with electrocardiograms (ECGs) is recommended as a means of targeting this scarce resource. There are data to support this policy when ECGs are interpreted by cardiologists but not by GPs.To assess the value of GP-reported ECGs as a pre-echocardiography screening test for left ventricular systolic dysfunction (LVSD).Cross-sectional study of GPs' ECG reporting skills.General practice, NHS in Scotland.A randomly selected, stratified sample of 123 Scottish GPs reviewed 180 ECGs (100 abnormal, 50 normal and 30 duplicate) from 150 patients with suspected heart failure. Forty-one patients had LVSD on echocardiography. GPs were required to categorise ECGs as normal or abnormal.Mean sensitivity was 0.94 (95% CI = 0.92 to 0.95). Mean specificity 0.58 (95% CI = 0.56 to 0.60). Mean positive predictive value (PPV) was 0.47 (95% CI = 0.46 to 0.48). Mean negative predictive value (NPV) was 0.96 (95% CI = 0.95 to 0.97). Mean likelihood ratio was 2.39 (95% CI = 2.28 to 2.50). Seventy of 123 (57%) GPs achieved sensitivity of 0.9 and specificity of 0.5 for the detection of LVSD.Most Scottish GPs have the skills to perform pre-echocardiography screening ECGs in patients with suspected LVSD. However, differences in ECG reporting performance between individual GPs will result in widely varying referral rates for echocardiography and differences in the detection rate of LVSD. The implications of these findings need to be considered when heart failure diagnostic services are being developed.

Background In coronary artery disease (CAD), a potentially reversible factor leading to cardiac death is left ventricular hypertrophy (LVH). However, LVH will only have a large impact overall in CAD if it is highly prevalent. Therefore we aimed to assess the prevalence of LVH in patients with stable, treated angina and its relationship with blood pressure (BP). Methods Three hundred twenty-two consecutive patients with angiographically confirmed coronary artery disease were recruited. Echocardiographic LV mass was performed and correlated with both office and 24-h ambulatory BP. Results Of the 267 patients with LV mass measurements, 195 (73%) had LVH. The mean 24-h ambulatory BP reading was systolic 125 ± 12 mm Hg and diastolic 68 ± 8 mm Hg in the LVH group. Of the LVH patients 62% had a nonhypertensive 24-h BP reading. On multivariate logistic regression analysis, factors independently related to LVH were history of hypertension (odds ratio [OR] 1.848, 95% confidence interval [CI] 1.051–3.248), body mass index (OR 1.085, 95% CI 1.011–1.165), and age (OR 1.039, 95% CI 1.004–1.076). Conclusions We conclude that echo LVH is very common in patients with stable, treated angina and the majority of these patients had a nonhypertensive BP at the time of study. Studies are now required to determine whether identifying and vigorously treating LVH in CAD would reduce the risk of premature death in these patients.

Recent evidence points to a role for the renin-angiotensin-aldosterone system (RAAS) in the pathogenesis of atherosclerosis and its complications, including acute angina pectoris. Two large trials in heart failure have clearly demonstrated that blocking aldosterone improves mortality1,2 and that this benefit occurs over and above standard therapy with angiotensin-converting enzyme (ACE) inhibitors. The question that naturally arises from these landmark studies is whether aldosterone blockade would produce the same benefits in patients with coronary artery disease (CAD) but no heart failure. There are three reasons to believe this might be the case. Firstly, angiotensin II (Ang II) and aldosterone produce similar biological effects and Ang II withdrawal has been shown to benefit patients with angina; aldosterone blockade may therefore follow in the footsteps of ACE inhibitors, as it did in heart failure, and produce benefits in vascular patients without heart failure. Secondly, one of the main mechanisms which is thought to be responsible for the benefit of aldosterone blockade in the Randomised ALdactone Evaluation Study (RALES) and Eplerenone Post-AMI Heart Failure Survival Study (EPHESUS), is that it improves endothelial/ vascular function3,4 and endothelial/vascular dysfunction is the fundamental abnormality in angina pectoris. Finally, aldosterone blockade has been shown to reduce atherosclerosis in animal studies of atherosclerosis without heart failure, which are analogous to CAD patients.5

To find out whether B-type natriuretic peptide (BNP) detects silent myocardial ischaemia in patients with type 2 diabetes, since many of these patients have silent ischaemia leading to unexpected cardiac deaths.Prospective cross-sectional study with consecutive recruitment of patients.Outpatient, single centre.219 patients with type 2 diabetes. Patients were excluded if they had a history or evidence of cardiac failure.BNP, echocardiography and exercise tolerance test (ETT). BNP was compared with the ETT result in all patients and specifically in those who had no apparent ischaemic heart disease (IHD).121 patients had no history of IHD or cardiac failure and of these patients 85 had a clearly abnormal or normal ETT result. BNP was higher in patients with an abnormal than with a normal ETT (mean 58.2 (SD 46.3) v 24.4 (SD 15.7) pg/ml, p0.001). In univariate analysis BNP was an independent predictor of an abnormal ETT (p0.001). In multivariate analysis BNP remained an independent predictor of the ETT result. BNP concentration over 20 pg/ml predicted an abnormal ETT result with a sensitivity of 87% and specificity of 37%, and BNP over 40 pg/ml had a sensitivity of 63% and a specificity of 81%.BNP is of value in predicting silent ischaemia on exercise testing in asymptomatic patients with type 2 diabetes.

Background: ECG and BNP have been assessed as screening tests for LVSD and heart failure. However, echocardiography also provides information about valvular disease and LVH. We assessed how good these screening tests are in identifying whether the subsequent echocardiogram will have any significant abnormality. Aims: To re-appraise the ECG and BNP as screening tests for echocardiography since there are important practical deficiencies in our current knowledge in this area. Methods: General practitioners referred suspected heart failure patients for clinical assessment, echocardiography, electrocardiography, and BNP measurement. The accuracy of each screening test and combinations of screening tests were calculated for LVSD, heart failure, valvular disease, and LVH. Results: The sensitivities of the ECG for LVSD, heart failure, LVH and valvular disease were 97%, 95%, 76%, and 69%, respectively. The corresponding figures for BNP were 86%, 82%, 59%, and 48%, respectively. When patients with atrial fibrillation and murmurs were excluded, the values for ECG were 94%, 87%, 53%, and 55%, while for BNP they were 83%, 73%, 50%, and 32%. Conclusions: ECG interpretation and BNP are adequate screening tests to detect LVSD or heart failure but fail to screen for other echocardiographic abnormalities, like valvular disease and LVH. This remains the case even if patients with atrial fibrillation or heart murmurs are excluded on the basis that they require echocardiography anyway.

Three studies have clearly shown that a prolonged QT dispersion (QTD) is the best predictor of cardiac death in patients with type 2 diabetes mellitus (DM). This was originally believed to be because QTD identified electrical inhomogeneity, but recent data suggests that this is unlikely. The alternative possibility is that QTD is a convenient identifier of hidden but lethal cardiac abnormalities. We explored whether the latter possibility is true by examining exactly what spectrum of cardiac abnormalities, if any, are over-represented in diabetics with a prolonged QTD. Two hundred nineteen patients with type 2 DM who had been first diagnosed with DM 3 to 6 years previously underwent intensive cardiac examinations. Patients with prolonged QTD had a significantly increased incidence of myocardial ischemia and left ventricular (LV) hypertrophy, and to a lesser extent, autonomic dysfunction. The main independent determinant of a prolonged QTD was ischemia, as seen on both ambulatory ST-segment monitoring (p

Introduction The presence of pulmonary hypertension in left ventricular systolic dysfunction (LVSD) is an ominous sign. It remains unclear the level at which pulmonary hypertension conveys a mortality risk in patients with LVSD. Methods We performed a record-linkage study in Tayside, UK (population approximately 400 000) utilising the Tayside echocardiogram database (>100 000 echo9s) maintained by the Health Informatics Centre (HIC). Datasets from HIC include mortality data and other health care activities linked anonymously by the community health index (CHI) number. Patients were included in the analysis if they had LVSD and had a right ventricular systolic pressure (RVSP) measurement. Cox proportional hazards regression analysis was used to examine the effects of different ranges of RVSP measures on all cause mortality. Results 2910 patients (mean age, 74.5±11.4 years; 43 % male) met entry criteria. Mean RVSP was 43.3 ± 12.7 mm Hg and median follow was 362 days (IQR 129–850 days). There was a significant correlation between RVSP and survival (p Conclusion An RVSP of greater than 42 mm Hg is predictive of increased mortality in heart failure. This is finding is independent of LVSD and COPD.

Large-scale trials of angiotensin converting enzyme (ACE) inhibitors after acute myocardial infarction (AMI) suggest that the benefits are greatest in patients with left ventricular (LV) dysfunction. However, early evaluation of LV function in all patients after AMI by current methods can be difficult due to a lack of resources and skilled personnel. Thus a clinical algorithm that could be used at the bedside to reliably identify patients with a left ventricular ejection fraction (LVEF)or = 40% would be helpful as an occasional alternative to echocardiography. We have devised such an algorithm based on the presence of one of: (i) clinical signs of heart failure; (ii) an index Q-wave anterior myocardial infarction; (iii) lack of thrombolytic therapy when there is a history of two or more previous myocardial infarctions and a CK rise1000 U/l. We tested this new algorithm prospectively in the coronary care units of two hospitals (one UK and one USA). In the UK centre, the sensitivity and specificity of the algorithm at identifying patients with a LVEFor = 40% were 82% and 72%, respectively. In the US centre, the sensitivity of the algorithm was 91% and the specificity 78% at identifying patients with LV dysfunction. We have validated a simple clinical algorithm which can be used at the bedside for identifying patients who would benefit from an ACE inhibitor after AMI.

OBJECTIVE--To evaluate the waveforms of left atrial area changes obtained by automated boundary detection with newly developed acoustic quantification technology. DESIGN--All subjects had measurements of left atrial areas taken in the apical four chamber, parasternal long axis, and parasternal short axis views using both conventional echocardiographic methods and automatic boundary detection on two occasions separated by at least a week. On the second visit measurements were also repeated in healthy volunteers after acute intravenous volume loading with 1 litre of saline over 2-5 minutes. SETTING--A university medical school echocardiographic laboratory. SUBJECTS--12 healthy male volunteers and 8 patients with cardiac disease (5 with congestive heart failure, 1 with mitral stenosis, and 2 with hypertensive left ventricular hypertrophy, and dilated left atria). RESULTS--There was close correlation between conventionally derived left atrial areas and those obtained by automatic boundary detection, particularly in the apical four chamber view (r = 0.98). Both inter and intra observer variabilities (coefficient of variation) for left atrial areas measured by automatic boundary detection were good (4.7-14.2% and 8.1-18.6% respectively). The reproducibility (coefficient of variation) for derived indices of left atrial function, however, was much poorer (10.4-104.8% and 12.5-88% respectively). After acute volume loading significant increases in left atrial area were observed at all stages in the cardiac cycle. CONCLUSIONS--These data demonstrate that although the reproducibility of left atrial functional indices is poor, instantaneous left atrial cavity measurements with automatic boundary detection are reproducible. This suggests that automatic boundary detection may assist in serial non-invasive measurement of left atrial size to assess disease states and treatments.

Background Controversy exists regarding the importance of glycaemic control in patients with type 2 diabetes mellitus (T2DM) and chronic heart failure (CHF) based on conflicting reports that had used a single baseline HbA1c. Objective To examine the relationship between the mean of all HbA1c measures after CHF diagnosis and outcome in a large cohort of T2DM patients with incident CHF. Design Retrospective, observational cohort study. Setting Tayside, Scotland. Patients T2DM patients with incident CHF between 1993 and 2010. Measurement A weighted mean HbA1c was calculated using all available HbA1c measures following CHF diagnosis and patients were grouped into five categories of HbA1c (≤6%, >6–≤7%, >7–≤8%, >8–≤9% and >9%). We subsequently compared diet and drug treated populations. The relationship between mean HbA1c and all-cause deaths after CHF diagnosis was assessed. Results 795 patients with T2DM met study criteria. Median follow-up of 3.8 years saw 491 (61.8%) deaths. Cox regression model, adjusted for all other significant predictors, with the middle HbA1c category (>7–≤8%) as the reference, showed a U shaped relationship between HbA1c and outcome. ( 6–≤7% [1.29 (1.01 to 1.66)] and >9% [1.38 (1.03 to 1.84)]. We found a similar relationship in the drug treated sub-group. However in the diet only group, low HbA1c was associated with the lowest risk of death (≤7% [0.17 (0.07 to 0.39)]). Conclusions In patients with T2DM and CHF, our observational study shows that in drug treated patients there was a U shaped relationship between HbA1c and mortality with the lowest mortality risk in patients with modest glycaemic control (HbA1c, >7–≤9%). However in diet treated patients, lower HbA1c was associated with lower mortality risk.

Background As IT dominates cardiology, the ability of centres to link clinical databases to perform outcome based research has increased significantly. Good quality research relies on the ability to accurately identify and characterise the disease of interest in the population. Heart Failure is one such disease that is often challenging to define from datasets. Uniquely we have the ability to link the Tayside echocardiography dataset to other regional datasets including dispensed prescription and hospitalisation data. Echocardiography reports are commonly comprised of structured, usually numerical values, and a free text component to store overall conclusions or impressions. We therefore sought to develop a computer algorithm to determine LV function from the free text and subsequently to validate the ability to define systolic HF based upon LVSD and loop diuretic therapy. Methods We iteratively the algorithm to process the free text component the reports and determine the degree of impairment. The algorithm was comprised of a lexicon of words and phrases and applied with negation detection. This was repetitively enhanced by recurrent processing of a subset of the data. The final algorithm was subsequently applied to the full dataset and was validated, first, against blinded manual review of a subset of reports and second by blinded review of the stored images. The data were then linked using a unique patient identifier to the dispensed prescribing data to determine loop diuretic use. The specificity of diagnosis of systolic heart failure was examined by blinded case note review. Results The database contained 153 836 reports on 63 309 individuals. The lexicon comprised 488 keywords or phrases. When applied to the data 145 525 reports were classified (94.4%), while 8584 remained unclassified. (5969 (70%) contained no information in the free text fields, and the remainder provided either insufficient data on left ventricular function or severe spelling or typographical errors, preventing matching.) 19 758 were classified as having LVSD (5378 (27%) mild, 818 (4%) mild to moderate, 4646 (24%) moderate, 583 (3%) moderate to severe and 8333 (42%) severe). The validation of 1000 reports reviewed for the presence or absence of LVSD found concurrence with the algorithm in 980 (98%) cases. Blinded review of the stored movies and images revealed a 90% concordance for the presence or absence of LVSD. Record linkage with the dispensed prescription dataset identified 9875 individuals with LVSD who also received loop diuretic therapy. Validation, by case note review, demonstrated a 91% concordance with a clinical diagnosis of systolic HF. Conclusion A computer algorithm can quickly and accurately identify the degree of LVSD from the free text component on an echocardiogram report and the presence of LVSD and combined with loop diuretic use is specific for a diagnosis of systolic heart failure.

Summary In view of the increased risk of cardiac events in systemic hypertension, particularly in patients with left ventricular hypertrophy, it is important to have reliable methods of assessing cardiac structure and function and myocardial perfusion in these patients. While echocardiography is the noninvasive method of choice for measuring the severity of left ventricular hypertrophy there is no alternative at present to invasive coronary angiography to define accurately coronary artery anatomy. Nuclear cardiological investigations are extremely useful in the assessment of systolic and diastolic function at rest and during exercise. Furthermore, myocardial perfusion imaging is of value in identifying myocardial ischaemia and assessing the functional importance of coronary artery lesions. Recent studies have also suggested that nuclear cardiology investigations may be the best way to identify nonfunctioning but viable areas of the myocardium which may benefit from revascularization.

Background Volume overload seen in mitral regurgitation (MR) leads to neuro-endocrine activation including heightened sympathetic activity. Experimental data have reported protective effects of beta-blockers (BBs) on myocardial function in MR suggesting that BB therapy may be beneficial in MR. However, the effect of BB therapy on clinical outcomes in MR has not been defined. Hence, in this large observational study we investigated the impact of BB therapy on clinical outcome in patients with moderate to severe MR. Methods The Health Informatics dispensed prescribing, morbidity and mortality database for the population of Tayside, Scotland was linked through a unique patient identifier to the Tayside echocardiography database (>110 000 scans). Patients with a diagnosis of moderate or severe MR from 1993 to 2008 were identified. Cox regression model (adjusted for age, gender, left ventricular dimensions and function, left atrial diameter, cardiovascular (CV) history and concurrent CV medications) was used to assess the impact of BB therapy on all-cause mortality and cardiovascular events (CV death or hospitalisations). Results A total of 4437 patients with moderate to severe MR (mean age 74 ±11 years, 46% males) were identified. MR was categorised as functional in 2523 (57%) and organic in 1894 (43%) while 1324 (30%) were on BBs. Over a mean follow-up of 3.9 years there were 2287 (51%) all-cause deaths and 2333 (52%) CV events. Those treated with BBs had a significantly lower all-cause mortality with an adjusted HR of 0.65 (95% CI 0.56 to 0.75, p Conclusions This large observational study suggests that BB therapy is associated with an improved survival and a lower risk of CV events in patients with moderate to severe MR. These observations needs to be confirmed in prospective studies and support the rationale for undertaking a future randomised clinical trial.

M-mode echocardiograms of 202 cardiac patients were studied with respect to the pattern of left ventricular (LV) geometry. Patients with normal LV mass and volume were separated from those who had LV hypertrophy or enlargement on the basis of LV mass and volume indexed to body surface area. The relative wall thickness that is currently used to classify LV hypertrophy/enlargement was found to be inadequate for differentiating between concentric and eccentric types of LV hypertrophy. A new M-mode echocardiographic classification is therefore proposed that accurately separates the different types of LV enlargement; it also allows identification of patients who have chronically dilated left ventricles at the expense of thin walls and thus have normal LV mass.

BACKGROUND--Classically, the ST-T configuration in the electrocardiogram of patients with left ventricular hypertrophy is said to have a typical pattern of ST depression together with asymmetrical T wave inversion (the so-called left ventricular strain pattern). However, many patients with left ventricular hypertrophy may also have ischaemic heart disease. To revise the electrocardiographic criteria for left ventricular hypertrophy the ST-T configuration in patients with left ventricular hypertrophy documented by echocardiography and with normal coronary arteries was assessed. METHODS--24 patients were selected for this study. All had left ventricular hypertrophy documented by echocardiography, normal coronary arteries by cardiac catheterisation, and ST and/or T wave abnormalities in the lateral leads of their electrocardiogram. There were eight patients with aortic valve disease and 16 with hypertension who had coronary angiography as part of an investigation into the risk factors of sudden cardiac death caused by hypertensive left ventricular hypertrophy. No patient was receiving digitalis preparations or had electrolyte disturbances, and none had a previous myocardial infarction or ventricular conduction defect. RESULTS--Typical electrocardiographic evidence of left ventricular strain was found in approximately two thirds (63%) of patients and 95% of this subgroup had asymmetrical T wave inversion. Flat ST segment depression, with or without T wave inversion or isolated T wave inversion (symmetrical or asymmetrical) in the anterolateral leads, was seen in the remaining 37% of patients. CONCLUSIONS--These findings indicate that left ventricular hypertrophy without coronary artery disease can cause variable types of ST-T abnormalities in the anterolateral leads including the typical left ventricular strain pattern and non-specific ST-T changes. Non-specific abnormalities could not be distinguished from those of coronary artery disease and may adversely affect the accuracy of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy because they do not accord with the criteria for left ventricular strain.

To determine electrocardiographic changes and whether myocardial ischemia occurs during cesarean section, electrocardiograms were recorded continuously using Holter monitoring in 25 patients undergoing elective cesarean section under either spinal or epidural anesthesia. In addition, in 13 of the patients, two-dimensional precordial echocardiography was carried out before and during cesarean section. ST segment depression suggestive of myocardial ischemia occurred in 16 patients including 8 of the 13 with echocardiograms. Wall motion remained entirely normal during episodes of ST segment depression. Patients in whom ST depression developed had significantly more rapid heart rates at delivery than those who did not experience ST depression. We conclude that ST segment depression is a common feature of the electrocardiogram during cesarean section under regional anesthesia and is not the result of myocardial ischemia.

Left ventricular dimensions were measured on M-mode echocardiograms, both by the Penn Convention and the Recommendations of the American Society of Echocardiographers in a sample cardiac population. The measurements of interventricular septum and the posterior wall of the left ventricle were significantly larger (P less than 0.001) using American Society Recommendations compared to using the Penn Convention. However, the left ventricular internal dimension at end-diastole was significantly larger (P less than 0.001) when measured by the Penn Convention. As a result of the differences in left ventricular dimensions, the left ventricular mass indexed to body surface area was significantly higher (P less than 0.001) using American Society as opposed to Penn measurements. On the other hand, left ventricular volume indexed to body surface area was significantly higher (P less than 0.001) on Penn measurements than on American Society estimates. These differences should be considered in any study where criteria of normality are to be applied. Good positive correlation (r greater than 0.9) between Penn and American Society estimates of indexed left ventricular volume allowed development of a regression equation to convert volumes from one convention to another. As a result, an upper normal limit of 100 ml/m2 for indexed left ventricular volume is suggested for measurements made using the Penn Convention.