Background Findings of large randomised trials have shown that lowering LDL cholesterol with statins reduces vascular morbidity and mortality rapidly, but limited evidence exists about the long-term efficacy and safety of statin treatment. The aim of the extended follow-up of the Heart Protection Study (HPS) is to assess long-term efficacy and safety of lowering LDL cholesterol with statins, and here we report cause-specific mortality and major morbidity in the in-trial and post-trial periods.Methods 20 536 patients at high risk of vascular and non-vascular outcomes were allocated either 40 mg simvastatin daily or placebo, using minimised random isation. Mean in-trial follow-up was 5.3 years (SD 1.2), and post-trial follow-up of surviving patients yielded a mean total duration of 11.0 years (SD 0.6). The primary outcome of the long-term follow-up of HPS was first post-randomisation major vascular event, and analysis was by intention to treat. This trial is registered with ISRCTN, number 48489393.Findings During the in-trial period, allocation to simvastatin yielded an average reduction in LDL cholesterol of 1.0 mmol/L and a proportional decrease in major vascular events of 23% (95% CI 19-28; p<0.0001), with significant divergence each year after the first. During the post-trial period (when statin use and lipid concentrations were similar in both groups), no further significant reductions were noted in either major vascular events (risk ratio [RR] 0.95 [0.89-1.02]) or vascular mortality (0.98 [0.90-1.07]). During the combined in-trial and post-trial periods, no significant differences were recorded in cancer incidence at all sites (0.98 [0.92-1.05]) or any particular site, or in mortality attributed to cancer (1.01 [0.92-1.11]) or to non-vascular causes (0.96 [0.89-1.03]).Interpretation More prolonged LDL-lowering statin treatment produces larger absolute reductions in vascular events. Moreover, even after study treatment stopped in HPS, benefits persisted for at least 5 years without any evidence of emerging hazards. These findings provide further support for the prompt initiation and long-term continuation of statin treatment.

Background Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial.Methods 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or. glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. in the conventional group, the aim was the best achievable FPG with diet atone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye,or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy.Findings Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group-an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0.34) for any diabetes-related death; and 6% lower (-10 to 20, p=0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints the three intensive agents (chlorpropamide, glibenclamide, or insulin).Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p<0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg).Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.

The St Vincent Declaration was the outcome of a meeting sponsored jointly by the World Health Organisation and the International Diabetes Federation in the Northern Italian town of St Vincent in 1989. Its stated aim was to improve the quality of medical care received by patients with diabetes, in particular the prevention of complications. The declaration gave priority to the establishment of comprehensive and reliable databases detailing the provision of care and its efficacy at both local and national level. Within the United Kingdom a task force, established by the Department of Health and the British Diabetic Association, set up a series of subgroups, which have now reported on several priority areas including cardiovascular disease.' Physicians are familiar with the heavy toll exacted by cardiovascular disease among diabetic patients. Coronary heart disease is two to three times more common among diabetic men and four to five times more common among premenopausal women.2' Myocardial infarction has a higher case fatality in diabetic patients and is responsible for nearly half of all deaths; among survivors heart failure is a more likely sequel than for non-diabetic patients. At a time of increased interest in the prevention of coronary disease the report provides a reminder of the opportunities for prevention among those who are diabetic.' Although the classic risk factors for coronary disease may have less relative effect in the presence of diabetes an increased absolute risk means that the attributable risk is also greater. Cigarette smoking and hypertension merit particular attention by health professionals in regular contact with diabetic patients particularly in primary care and diabetic clinics. It has been calculated that stopping cigarette smoking would reduce coronary heart disease deaths by 15% and effective control of hypertension by 6%.4 Control of hypertension also slows the deterioration of renal function caused by diabetic nephropathy. The report of the cardiovascular subgroup was prepared before publication of two studies which demonstrate the benefit of HMG Co-A reductase inhibitors5 6 and so the value of treating moderate hyperlipidaemia in the prevention of coronary disease among diabetic patients may have been underestimated.7 The ongoing Heart Protection Study will provide additional guidance on the value of statins among diabetic patients with and without overt evidence of vascular disease, although isolated hypercholesterolaemia is not the most frequent lipid abnormality encountered in diabetes mellitus and so other lipid-lowering drugs may play a more important part. The cardiologist is addressed most specifically on the management of symptomatic coronary disease which is

The Sixth Biennial Survey of Staffing in Cardiology was conducted in July 1990. This report summarises the data that were collected, together with the results of a survey of facilities in cardiology made in 1989. The total number of cardiologists in the United Kingdom, defined as individuals trained in the specialty and spending at least 40% of their time working in it, is now 323. Six individuals work part time only, making 320 whole time posts. This number has increased over the two years from 1988 to 1990 by 32, of which 23 work only in the specialty and nine as general physicians with a major interest in cardiology. The rate of increase in numbers over the past decade has been reasonably consistent with an average of approximately 4.4% per year. Thirty one districts in England and Wales still have no cardiologist and 13 other districts have little provision with an average of three (visiting) sessions each per week. The population in these 44 districts is 8.3 million. Scotland also has an inadequate distribution of service in the specialty. If recommendations for cardiac surgery and angioplasty made in the Fourth Report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England are to be met, we calculate that we need 63 more cardiologists in our major centres. To provide one cardiologist in every district hospital and two for larger districts would require 94 more specialists, making a total shortfall of 157 individuals. We have no excess of senior registrars to provide for a major expansion at consultant level. Time spent within the senior registrar (or academic equivalent) grade has tended steadily to decline and very few now reach the end of their contracts. The need for more individuals to pass through the senior registrar grade will be met in part by a planned reduction in the training period to three years. This will be inadequate, however, because projected retirements show that the number of consultant vacancies will increase sharply from 1997. We believe that additional senior registrar posts must be created if a serious shortfall in service provision by consultants is to be avoided. The provision of non-invasive facilities in cardiology is reasonable. The need for additional equipment for invasive cardiology has not been assessed. The number of physiological measurement technicians varies considerably between regions and is generally inadequate.

It is common practice among physicians to urge patients with ischvmic heart disease to abstain from the use of tobacco.The exact scientific evidence on which this advice is based is not always clear although some papers offer suggestive evidence that smoking impairs the performance of the heart already damaged by disease of the coronary arteries (Pickering and Sanderson, 1945; Davis et al., 1956).With the development of a method to make frequent measurements of the cardiac output without discomfort or risk to the patient (Gabe, Tuckman, and Shillingford, 1962), it has been possible to make a quantitative assessment of cardiac performance before, during, and after smoking.The purpose of this paper is to define more accurately the acute effects of smoking and nicotine on the circulation in those patients who are suffering from ischimic heart disease, with or without myocardial infarction, and to compare them with the response in normal subjects. SUBJECTS AND METHODSStudies were carried out on 33 patients who can be conveniently divided into three groups: (1) 14 volun- teers with a normal cardiovascular system; (2) 5 patients with angina but no evidence of myocardial infarc- tion; and (3) 14 patients with historical, clinical, and electrocardiographic evidence of myocardial infarction.The distribution of patients between the three groups and their ages are shown in Table I.Although there is some overlap in the age ranges in the groups, the average age of the patients with myocardial ischoemia is higher than among the normal subjects.Among the 14 patients in the myocardial infarction group, 7 had had their infarction between three and six weeks before the smoking test was performed; the remaining 7 patients had their acute episode more than six months before the test.The majority of the subjects were men; there were two women in both the normal and myocardial infarction groups and one in the angina group.All patients studied were smokers with the exception of one normal subject.Each patient was studied approximately two hours after lunch.No premedication was required but the nature of the procedure was fully explained to the patient, and each was allowed to rest quietly on a couch before measurements were commenced.The technique of measuring the cardiac output during cigarette smoking was as previously described from this laboratory by Irving and Yamamoto (1963).With the patient resting in the supine position, the couch being tilted 100 feet down from the horizontal, frequent measurements were made of pulse rate, blood pressure by sphygmomanometry, and of the cardiac output relative to the resting state by the dye dilution method.For each estimation of the cardiac output, approximately 35 mg. of Coomassie Blue were used.When a steady state had been reached the patient smoked a single cigarette, except for two patients in the post-infarction group who smoked pipes.No attempt was made to regulate the cigarette smoking with regard to either rate or depth of inhalation, but under the circumstances we found that patients tended to smoke fairly rapidly, and the average time taken to smoke one cigarette was 6 to 7 minutes.The cigarettes smoked were common commercial brands, and since the quantity of nicotine absorbed is little influenced 422on July 20,