Contemporary issues in the management of patients with coronary artery disease across the cardiology spectrum

Abstract

Volume 4 of Continuing Cardiology Education focuses on the treatment of patients with coronary artery disease, CAD. All European cardiologists need to have a thorough knowledge of the issues that are discussed, since despite advances in our understanding of the prevention of CAD, patients suffering from its consequences increasingly seek help from cardiologists across all European countries and across all the subspecialty areas of cardiology. The authors of the articles are all practising clinicians working in an area with a particularly high prevalence of coronary artery disease, the North East of England. The regional cardiothoracic centre at The James Cook University Hospital in Middlesbrough serves a population of around 1.5 million people across Teesside, County Durham, North Yorkshire and Cumbria. The authors have drawn on their day to day experience of treating patients alongside the published literature to provide, for both the trainee in cardiology and the established specialist, a review and update of the essential knowledge needed to understand contemporary clinical practice. Where appropriate, the authors have referred to existing ESC guidelines. It must be remembered that not all the guideline recommendations can be based on firm evidence from randomized control trials or high quality observational research and there are unfortunately still a large number of recommendations based on only “expert opinion”. Where possible, we must work harder to reduce these sources of uncertainty with more research. It is also critical for us to be aware that when applying guidelines to individual cases, we need to know the strengths and weaknesses of the underlying evidence so that that guideline recommendations can be appropriately applied to a plan of care for an individual patient and not just follow a “one size fits all” approach.

For trainees in cardiology, the knowledge required across this area of cardiology is set out in the ESC Core Curriculum for General Cardiology (see particularly chapters 2.8 and 2.9) and how the acquisition and application of this knowledge fits into overall training is set out in the Training Requirements for the Specialty of Cardiology from the UEMS 1, 2.Readers will be able to confirm their understanding of the material and gain EBAC CME credits by completion of the series of formative MCQs that have been prepared in conjunction with each of the articles. These MCQs have been modeled on the style of question used in the European Examination of General Cardiology, that is, there is a clinical stem, a single question followed by five possible answers with the need to select the single best answer. Further details about the EEGC are available at the UEMS-Cardiac Section website 3. Completion of the formative MCQs can be used as evidence of successful knowledge acquisition, for example, for ongoing specialist revalidation or for the European Diploma of General Cardiology 4.

Coronary artery disease, CAD, is a common contributor to or bystander of cardiac arrhythmias. Dr Ruairidh Martin and Dr Matt Bates have provided a practical guide to the management of atrial fibrillation, AF, in patients with concomitant CAD, including an update on the rapidly evolving area of appropriate antithrombotic therapy in the context of AF and CAD. Dr Dewi Thomas and Dr Andrew Thornley have looked at the basic mechanisms underlying ventricular arrhythmia in the different presentations of CAD and given us and some practical guidance for treatments.

Coronary artery disease can present to the practicing cardiologist in the stable phase or as an acute coronary syndrome. Dr Thandar Aye and Dr Richard Graham outline their approach to the assessment of prognosis in the patient with stable disease. They have provided insights into the evidence relating to the pros and cons of the commonly available imaging modalities used every day in our clinics. Dr Alex Brown and Dr David Austin have looked at the question of which antiplatelet therapy to use in CAD patients presenting with an acute coronary syndrome. This is a relatively evidence-rich area of clinical practice but nevertheless still throws up practical questions for day to day practice. In order to make balanced judgments of the best advice for individual patients, we need a thorough understanding of the strengths and weaknesses of the evidence base. Their comprehensive review of this important topic contains messages that we can take away and apply to our patients.

Heart failure is an increasing problem with an increasingly aged population and CAD is a common cause. Dr Pamela Brown and Dr Jeet Thambyrajah have provided an evidence-based approach to the management of patients with both acute and chronic heart failure.

Cardiology is a rapidly developing area for the established clinician and the developments have often been driven by quantum leaps in technology. Cardiac magnetic resonance imaging is underpinned by complex theories of subatomic physics and has the potential to redefine our traditional approaches to investigation and monitoring of cardiovascular disease. Dr Alexandra Thompson and Dr Neil Maredia have provided an up-to-date guide to what they call the “comprehensive IHD assessment” with a basic outline of their approach using the techniques of LV cine stacks, edema imaging, stress myocardial perfusion, rest myocardial perfusion, early and late Gadolinium enhancement. How and when to use these techniques and how to interpret the results will be a key part of the knowledge and skills of all practising cardiologists, not just cardiac imaging subspecialists. Another new development driven by improved technology in material science is transarterial aortic valve implantation, TAVI, where the engineering of the implant devices has permitted safe and effective percutaneous delivery. Dr Muzaffar Mahmood and Dr Douglas Muir have reviewed the vexing issue of how best to manage concomitant CAD when a patient undergoes TAVI. This is currently the best example of highly individualized decision-making based upon clinical judgment rather than an extensive evidence base and the most convincing need for a well-functioning local multidisciplinary team. Also venturing into the world of materials science is the consideration of stent design by Dr Mohammed Awan and Dr Paul Williams—what stents to use and when and why, and how to more critically appraise potential pitfalls in stent design.

We hope that trainees and specialists find these reviews and updates valuable. We hope that the formative MCQs will be used to confirm the assimilation of the information presented. We have attempted in this issue to emphasize the importance to all cardiologists of knowledge across the spectrum of “sub-specialty areas”. In our experience, it is usually the case that patients do not confine their needs to a single area of cardiology and so the knowledge, skills, and behaviors needed for success in general cardiology will remain a basic requirement for all cardiologists well into the 21st century. Educational activities such as CCE will hopefully prosper and be widely available to help trainees and all practising cardiologists maintain their grounding in general cardiology.

Dr Hall and Dr Wright have nothing to disclose.