Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are global epidemics incurring significant morbidity and mortality. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. Evaluation of cardiac and pulmonary function is often problematic and occasionally misleading. Echocardiography and pulmonary function tests should be performed in every patient. Careful interpretation is required to avoid misdiagnosis and inappropriate treatment. Airflow obstruction, in particular, must be demonstrated when clinically euvolaemic. Very high and very low concentrations of natriuretic peptides have high positive and negative predictive values for diagnosing HF in those with both conditions. Intermediate values are less informative. Both conditions are systemic disorders with overlapping pathophysiological processes. In patients with HF, COPD is consistently an independent predictor of death and hospitalization. However, the impact on ischaemic and arrhythmic events is unknown. Greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. The resulting symptomatic and prognostic benefits outweigh those attainable by treating either condition alone.--

Background 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. Methods

63'0 (10)) with chronic atrial fibrillation. At the time of the study, 37 were taking no antithrombotic medication (group 1), 31 were taking warfarin (including two on warfarin and aspirin) (group 2) and 19 were taking aspirin alone (group 3). They were compared with 158 population controls from a random population sample (the second Glasgow monitoring trends and determinants in cardiovascular disease study). As part of clinical treatment warfarin was introduced in 20 patients with chronic atrial fibrillation (14 men and six women of mean (SEM) (range) age 63-9 (2.35 (32-74) years). Results-Plasma fibrinogen remained significantly increased in patients of group 1 (no antithrombotic medication) compared with that of the population controls (median difference 1*23 gil; 95% confidence interval (CI) 0-88 to 1*62, P < 0.0001). There was also a significant increase in plasma D-dimer levels (median difference 77 nglml; 95% CI 38 to 122, P < 0.01) and vWF (median difference 63 IU/dl; 95% CI 38 to 89, P < 0-0001). There was no significant difference in plasma fibrinogen (median difference 0-14 gil; 95% CI -0*44 to 0 77, P = 0.65) or vWF (median difference 3-5 IU/dl; 95% CI -41 to 41, P = not significant in patients of group 2 (warfarin treatment) compared with that. of patients in group 1. Levels of D-dimer were significantly lower in group 2 (median difference 90 nglml, 95% CI 39 to 150, P < 0*0001) than in group 1. There were no significant differences in plasma fibrinogen (median difference 0-08 gil; 95% CI -0-52 to 0 77, P = 0.73), D-dimer (median difference -34 nglml; 95% CI -114 to 21*0, P = 0.25), or vWF (median difference 2%; 95% CI -35 to 41, P = not significant) levels between patients of groups 1 and 3. There were no significant correlations between the coagulation indices and left atrial volume or ventricular function. There was a significant positive correlation between plasma fibrin D-dimer and vWF levels in patients of groups 1 and 3 (r= 0.52, P < 0001).There was a significant reduction in median plasma fibrin D-dimer levels at 2 months after the introduction of warfarin (181 nglml v 80 ng/ml, P < 0 001), but no effect on plasma fibrinogen. Conclusions-Increased median plasma fibrinogen and vWF levels were found in patients with chronic atrial fibrillation. Plasma D-dimer levels were also increased in patients with chronic atrial fibrillation not receiving warfarin, suggesting increased intravascular thrombogenesis in such patients. Introduction of warfarin normalised circulating fibrin Ddimer levels, suggesting that warfarin treatment was effective in preventing excessive fibrin turnover, consistent with the antithrombotic effects of warfarin.These results suggest three possible thrombotic markers to assess patients with atrial fibrillation who are at high risk of thrombogenesis; D-dimer also merits assessment as a measure of reduction in thrombotic risk in patients receiving warfarin. (Br HeartJ 1995;73:527-533)

Cachexia in HF is associated with an increase in adiponectin concentration. This may represent preservation of the physiological response to change in body fat but might also suggest that adiponectin plays a role in the pathogenesis of cachexia. The correlation between BNP and adiponectin also raises the possibility that the former might increase the secretion of the latter.

SUMMARY Systemic, renal and splanchnic hemodynamics, intravascular volume, circulating catecholamine levels and plasma renin activity were compared in 39 patients with borderline hypertension and 28 normotensive subjects, who were less than 5% (n = 42, lean patients) or more than 40% overweight (n = 25, obese patients). Lean borderline hypertensive patients had greater cardiac output (p < 0.05), heart rate (p < 0.01) and renal blood flow (p < 0.05); cardiopulmonary redistribution of intravascular volume (p < 0.05); and higher circulating norepinephrine levels (p < 0.05). Obese normotensive subjects also showed an increased cardiac output (p < 0.005), stroke volume (p < 0.01), left ventricular stroke work (p < 0.05), and renal blood flow (p < 0.05) (but not respective indexes), but intravascular volume was expanded (p < 0.05) without redistribution and circulating catecholamine levels were normal. Obese borderline hypertensive patients had hemodynamic characteristics similar to those of obese normotensive subjects except for an increased peripheral resistance (p < 0.05). The data indicate that although both populations have an increased cardiac output, the lean borderline hypertensive patients have signs of enhanced adrenergic activity as evidenced by higher circulating catecholamine levels and heart rate with blood volume translocation to the cardiopulmonary circulation. In contrast, the obese subjects (whether normotensive or borderline hypertensive), who also have increased cardiac output, seem to have normal adrenergic activity and an expanded intravascular volume without cardiopulmonary redistribution.YOUNG PATIENTS with borderline blood pressure values are at least three times more likely to develop established essential hypertension as age-matched normotensive subjects.'1 2 Elevated resting cardiac output and heart rate have been identified as predictors for the development of essential hypertension into a state with more persistently elevated arterial pressure and periph-

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Objective-To assess current strategies used to investigate and manage acute atrial fibrillation in hospital. Design-Prospective survey of all acute admissions over 6 months. Setting Atrial fibrillation is one of the most common cardiac arrhythmias among acute medical admissions to district general hospitals but there seems to be a wide range of views on its optimal management. This is not surprising as the management of the patient with atrial fibrillation is complicated by such things as diverse therapeutic options, concerns about anticoagulation, and the proarrhythmic effects of antiarrhythmic treatment. We report an audit relating to the investigation and management of patients admitted as emergencies with this dysrhythmia to a district general hospital, for a six month period between 1 September 1991 and 29 February 1992. MethodsThe hospital is a 990 bed district general hospital serving a population of 230 000 in the north east part of the city of Glasgow and the borough of Strathkelvin. The hospital has a coronary care unit with six medical wards, a renal ward and a large geriatric department. There are nine general physicians, one of whom has a major interest in cardiology. Also there is a full time cardiologist, two renal physicians and four physicians with an interest in geriatric medicine, none of whom undertake general medical receiving duties. The physicians were informed at the start of the study that an audit was going to take place as this is part of hospital protocol. Thereafter, the information was collected from the case records and no further discussions were held with the physicians involved.Patients were prospectively included in this study if they were found to be in established atrial fibrillation on the admission electrocardiogram, or had developed atrial fibrillation within 48 hours of admission. Patients were studied from the three medical units within the hospital, the coronary care unit the renal unit, and the geriatric wards.The mode of presentation, cardiac investigations carried out, the aetiology of atrial fibrillation, the treatment before and that initiated after admission, and the inpatient mortality were also noted. The survey therefore assessed the characteristics of the inpatients admitted with atrial fibrillation, duration of stay, whether the aetiology of atrial fibrillation was assessed, what investigations were undertaken, and what their impact on management was and also actual management undertaken on the patient. This was done at the time of admission, during their stay in hospital, and at the time of discharge.

AimsHeart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist and present major challenges to healthcare providers. The epidemiology, consultation rate, and treatment of patients with HF and COPD in primary care are ill-defined. Methods and resultsThis was an analysis of cross-sectional data from 61 primary care practices (377 439 patients) participating in the Scottish Continuous Morbidity Recording scheme. The prevalence of COPD in patients with HF increased from 19.8% in 1999 to 23.8% in 2004. In 2004, the prevalence was similar in men and women (24.8% vs. 22.9%, P ¼ 0.09), increased with age up to 75 years, and increased with greater socioeconomic deprivation (most deprived 31.3% vs. least deprived 18.6%, P ¼ 0.01). Contact rates for HF or COPD in those with both conditions were greater than disease-specific contact rates in patients with either condition alone. Although overall beta-blocker prescribing increased over time; the adjusted odds of beta-blocker prescription in patients with COPD was low and failed to improve [odds ratio 0.30 (0.28-0.32), P , 0.001]. In 2004, only 18% of individuals with HF and COPD were prescribed beta-blockers vs. 41% in those without COPD. ConclusionChronic obstructive pulmonary disease is a frequent comorbidity in patients with HF and represents a significant healthcare burden to primary care. Although beta-blocker prescribing in the community has increased, less than a fifth of patients with HF and COPD received beta-blockers.--