Craigavon, United Kingdom
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Kalra P.R.,Portsmouth Hospitals NHS Trust | Morley C.,Bradford Hospitals NHS Trust | Barnes S.,Servier Laboratories Ltd | Menown I.,Craigavon Cardiac Center | And 4 more authors.
International Journal of Cardiology | Year: 2013

Aims: The present study aims to investigate patterns of beta-blocker usage in a national primary care cohort. Methods and results: This is a retrospective cohort study utilising the UK General Practice Research Database from 2004 to 2008. Inclusion criteria were (i) a first diagnosis of chronic heart failure (CHF), myocardial infarction (MI) or angina, and (ii) first-ever prescription of beta-blocker on or after 1st April 2004. Outcome measures were discontinuation of beta-blockers over time, initiation dosages, titration patterns, incidence of adverse events (AEs) and associated prescribing actions. A total of 12,493 patients (68.0% male; mean age 58.0 ± SD 17.6 years) were included. Of these, 27% had discontinued beta-blockers within 1 year of initiation, increasing to 39% by 2 years and 50% by 3 years. Persistence appeared to be greater in the MI cohort compared with angina or CHF cohorts. Beta-blocker dose at initiation averaged approximately 33% of guideline recommended target, rising to 40% in those who continued with therapy. Dyspnoea, fatigue and dizziness were the most common incident AEs at 98, 53 and 49 per 1000 patient years, with little difference between indications. Conclusion: A quarter of patients with cardiovascular disease who are commenced on a beta-blocker are no longer taking the drug by one year. This rises to 50% by three years, a finding that is consistent irrespective of whether the prescription is for prognostic (CHF or post MI) or symptomatic (angina) benefit. There is an urgent need to understand and address the prescribing difficulties of beta-blockers in these at-risk patients. © 2012 Elsevier Ireland Ltd.


Menown I.B.A.,Craigavon Cardiac Center | Davies S.,Royal Brompton Hospital | Gupta S.,Whipps Cross and St Bartholomews Hospitals | Kalra P.R.,Portsmouth Hospitals NHS Trust | And 3 more authors.
Cardiovascular Therapeutics | Year: 2013

Background: Data from large epidemiological studies suggest that elevated heart rate is independently associated with cardiovascular and all-cause mortality in patients with hypertension and in those with established cardiovascular disease. Clinical trial findings also suggest that the favorable effects of beta-blockers and other heart rate-lowering agents in patients with acute myocardial infarction and congestive heart failure may be, at least in part, due to their heart rate-lowering effects. Contemporary clinical outcome prediction models such as the Global Registry of Acute Coronary Events (GRACE) score include admission heart rate as an independent risk factor. Aims: This article critically reviews the key epidemiology concerning heart rate and cardiovascular risk, potential mechanisms through which an elevated resting heart rate may be disadvantageous and evaluates clinical trial outcomes associated with pharmacological reduction in resting heart rate. Conclusions: Prospective randomised data from patients with significant coronary heart disease or heart failure suggest that intervention to reduce heart rate in those with a resting heart rate >70 bpm may reduce cardiovascular risk. Given the established observational data and randomised trial evidence, it now appears appropriate to include reduction of elevated resting heart rate by lifestyle +/- pharmacological therapy as part of a secondary prevention strategy in patients with cardiovascular disease. © 2012 John Wiley & Sons Ltd.


Lang C.C.,Ninewells Hospital and Medical School | Gupta S.,Whipps Cross And St Bartholomews Hospitals | Kalra P.,Portsmouth Hospitals NHS Trust | Keavney B.,Northumbria University | And 3 more authors.
Atherosclerosis | Year: 2010

There is an established body of evidence from epidemiological studies which indicates that an elevated resting heart rate is independently associated with atherosclerosis and increased cardiovascular morbidity and mortality, in both the general population and in patients with established cardiovascular disease. Clinical trial data suggest that in patients with coronary artery disease, an elevated heart rate identifies those at increased risk of adverse cardiovascular outcomes, and that lowering of heart rate may reduce major cardiovascular events in patients with an elevated heart rate and symptom-limiting angina. These results suggest that an increased heart rate may have an adverse impact on the atherosclerotic process and increase the risk of a cardiovascular event in patients with coronary artery disease. The precise pathophysiological mechanisms that link heart rate and cardiovascular outcomes have yet to be defined. Possibilities may include indirect mechanisms related to autonomic dysregulation and those due to an increase in heart rate per se, which can increase the ischaemic burden and exert local haemodynamic forces that can adversely impact on the endothelium and arterial wall. For these reasons, heart rate should be considered as a therapeutic target in the treatment of patients with coronary artery disease. © 2010 Elsevier Ireland Ltd.


Menown I.B.A.,Craigavon Cardiac Center | Noad R.,Craigavon Cardiac Center | Garcia E.J.,Hospital Cliniuco San Carlos | Meredith I.,Monash University
Advances in Therapy | Year: 2010

Despite advances in polymer and drug technology, the underlying stent platform remains a key determinant of clinical outcome. A clear understanding of stent design and the differences between various stent platforms are of increasing importance for the interventional cardiologist. Reduction in stent strut thickness has been associated with improved stent deliverability, improved procedural outcome, and lower rates of subsequent restenosis. Newer-generation 316L-SS stent designs have enabled reduced strut thickness while retaining radial strength and minimizing recoil, but with significant loss of radiopacity, leading to reduced visibility. Cobalt chromium alloys have enabled a reduction in stent strut thickness to around 80-90 mm while retaining modest radiopacity, but due to higher elastic properties, have been associated with greater stent recoil. Development of a novel 33% platinum chromium alloy with high radial strength and high radiopacity has enabled design of a new, thin-strut, flexible, easily visualized, and highly trackable stent platform, the use of which is further illustrated in several clinical case descriptions. © Springer Healthcare 2010.


Shand J.A.,Craigavon Cardiac Center | Kodoth V.,Craigavon Cardiac Center | Menown I.B.A.,Craigavon Cardiac Center
Interventional Cardiology | Year: 2011

To address concerns of late and very late stent thrombosis associated with first generation drug-eluting stent technology, novel approaches are being tested including stents with bioabsorbable polymers (including Biomatrix Flex™, Nobori™ and Synergy™), polymer-free drug delivery systems (including Biofreedom™ and Yukon®) and drug-eluting balloons (including Sequent Please™, Dior® II and Pantera Lux™). This article reviews the key clinical data evaluating these approaches and describes future directions for technology development. © 2011 Future Medicine Ltd.


Howe A.J.,Craigavon Cardiac Center | Shand J.A.,Craigavon Cardiac Center | Menown I.B.A.,Craigavon Cardiac Center
Future Cardiology | Year: 2011

Multiple key cardiology trials have been presented or published over recent months, several with the potential to change clinical practice. In this article, we summarize and place in clinical context new trial findings regarding anticoagulation in the cardiac catheterization laboratory (enoxaparin, fondaparinux and unfractionated heparin), the implications of genetic polymorphisms and functional testing for antiplatelet therapy (clopidogrel and ticagrelor), new oral anticoagulants for use in atrial fibrillation (apixiban and rivaroxaban), optimal pacing strategies and pharmacological agents in heart failure (ivabradine, eplerenone, cardiac resynchronization therapy, telemonitoring and intracoronary bone marrow stem cell infusion). Clinical trials in percutaneous structural intervention (transcatheter aortic valve implantation, MONARC™ mitral annular implant, STARFlex ® patent foramen ovale device) and advanced percutaneous coronary intervention (everolimus-eluting stents, biodegradable polymer/polymer-free technologies and contemporary use of intravascular ultrasound) are also discussed. © 2011 Future Medicine Ltd.


Shand J.A.,Craigavon Cardiac Center | Menown I.B.,Craigavon Cardiac Center
Interventional Cardiology | Year: 2010

The small but absolute increase in late and very late stent thrombosis associated with drug-eluting stent technology may in part be related to the permanent, durable polymers currently employed with these stent platforms. Research has recently focused on two strategies to combat this problem; bioabsorbable polymers and polymer-free stents. This article critically reviews the key clinical trials and recent conference updates surrounding these two approaches and future directions for technology development. © 2010 Future Medicine Ltd.


Shand J.,Craigavon Cardiac Center | Menown I.,Craigavon Cardiac Center | McEneaney D.,Craigavon Cardiac Center
Biomarkers in Medicine | Year: 2010

The diagnosis of acute myocardial infarction currently rests on the measurement of troponin, a biomarker of myocardial necrosis. Unfortunately, the current generation troponin assays detect troponin only 6-9 h after symptom onset. This can lead to a delay in diagnosis and also excessive resource utilization when triaging patients who, ultimately, have noncardiac causes of acute chest pain. For these reasons, there has been extensive research interest in biomarkers that can detect and rule out myocardial infarction early after symptom onset. These include markers of myocardial injury, such as myoglobin, heart-type fatty acid binding protein, glycogen phosphorylase BB; hemostatic markers, such as D-dimer; and finally, inflammatory markers, such as matrix metalloproteinase 9. Recently, highly sensitive troponin assays have reported an early sensitivity for myocardial infarction of greater than 95%, although at a cost of reduced specificity. The optimal strategy with which to use these novel biomarkers and highly sensitive troponins has yet to be determined, and interpretation of their results in light of thorough clinical assessment remains essential. © 2010 Future Medicine Ltd.


Menown I.,Craigavon Cardiac Center | Shand J.A.,Craigavon Cardiac Center
Future Cardiology | Year: 2010

During 2009, multiple major cardiology trials have been presented or published. In this paper, we summarize and place in clinical context the new trial findings regarding anticoagulation (dabigatran) , antiplatelet therapy (ticagrelor, clopidogrel, prasugrel and aspirin) , percutaneous coronary management (thrombectomy, multivessel/left main disease and biodegradable polymers), medical therapy for coronary disease (ivabradine and rosuvastatin) and management of heart failure (β-blocker strategy, atrial fibrillation and resynchronization therapy). Copyright © 2010 Future Medicine Ltd.


McNeice A.H.,Craigavon Cardiac Center | McAleavey N.M.,Craigavon Cardiac Center | Menown I.B.A.,Craigavon Cardiac Center
Advances in Therapy | Year: 2014

Multiple, potentially practice-changing cardiology trials have been presented or published over the past year. In this paper, we summarize and place in clinical context, new data regarding management of acute coronary syndrome and ST-elevation myocardial infarction (copeptin assessment, otamixaban, cangrelor, prasugrel, sodium nitrite, inclacumab, ranolazine, preventive coronary intervention of non-culprit lesions, immediate thrombolytic therapy versus transfer for primary intervention), new coronary intervention data (thrombectomy, radial access, pressure wire fractional flow reserve, antiplatelet therapy duration and gene-guidance, permanent and biodegradable polymers, coronary bifurcation and strategies), and coronary artery bypass data (off pump vs. on pump). Latest trials in trans-aortic valve implantation, heart failure (eplerenone, aliskiren, spironolactone, sildenafil, dopamine, nesiritide, omecamtiv mecarbil, the algisyl left ventricular augmentation device, and echo-guided cardiac resynchronization), atrial fibrillation (edoxaban, dabigatran, and ablation), cardiac arrest (hypothermia, LUCAS™ mechanical chest compression), and cardiovascular prevention (vitamins, renal denervation for resistant hypertension, renal artery stenting, saxagliptin, alogliptin, and gastric banding) are also discussed. © 2014, Springer Healthcare.

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