British Medical Bulletin 59:1-2 (2001)
© 2001 Oxford University Press
Preface
Ischaemic heart disease is common. In the UK alone, 250,000 present each year with acute myocardial infarction and a further 250,000 with unstable angina. In 1995, 2.2 million Americans were discharged from hospital with a diagnosis of coronary artery disease. The factors leading to the point of partial or complete coronary artery occlusion are multiple and complexly interactive. They include the basic developmental pathology of early vessel wall abnormalities, consequent on the interaction between haemostatic, hormonal, and various blood constituents (such as lipid fractions and glucose), and the cellular constituents of the vessel wall. Epidemiology is important in helping us to understand how and why atheromatous coronary disease presents clinically and how we might develop strategies to prevent it. Many of the therapeutic developments that have improved outcome in patients with coronary artery disease have come from our understanding of the pathology and from strategies tested in peripheral vascular disease. Thus knowing, for example, that thrombus formation has a central role in the initiation of acute coronary syndromes has led to the development of lytic therapy and the trialing of powerful antiplatelet drugs. Concepts of ventricular remodelling have emphasised and help explain the effectiveness of ACE inhibitor therapy, while an increasing understanding about which arrhythmia to treat and with what has improved patient survival.
Managing patients to improve outcome is not only about drug treatment however. Secondary prevention through lifestyle change and improving self confidence, perception and optimising quality of life through the implementation of rehabilitation programmes are as critical as getting the initial treatment right. Managing patients with coronary artery disease also involves revascularisation. Average rates world-wide are 600 per million for both percutaneous and surgical procedures. Issues such as use of stents and more recently how to prevent in-stent re-stenosis as well as choice of by-pass conduit and operative approach are all developments designed to improve the outcome of intervention. New developments such as the use of gene therapy to promote vessel collateral growth or alternative ways of treating chest pain in those patients who cannot be managed with conventional therapies are becoming available.
Picking out the important issues to represent the various components in the development, clinical presentation, therapeutic options and interventional management of ischaemic heart disease could never be regarded as an easy task. Convincing experts in the field to give up time to summarise and provide opinion on these various aspects is always difficult. However, we believe we have collected together an outstanding group of individuals all respected in their field, who have provided in this book contemporary opinions that go a long way to summarising what happens during the pathological events that take a vessel from being normal to being diseased. They have explained how such events translate into clinical presentation and how they form the basis for therapeutic strategies that alter the natural history of the disease.
The overall aim of this volume of the British Medical Bulletin was to provide an up to date evidence-based overview of the issues involved in the development and management of ischaemic heart disease to provide authority for the reader to alter, if necessary, their medical practice. We hope this aim will be achieved.
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