One of my patients has recently been diagnosed as having complete heart block. This patient has not presented with any other signs of ischaemic heart disease. Is the patient eligible for secondary prevention, or is it likely that this condition is being caused by a non-ischaemic process?
Usually, complete heart block is a condition of advancing age caused by fibrosis in the conducting system.
There are, of course, a number of other possible causes of this condition, such as ischaemic damage which is caused by MI. Another possibility is congenital complete heart block, which is occasionally seen.
I assume that your patient is typical and has been treated by being fitted with a permanent pacemaker. In that case, in the absence of any symptoms or history of vascular occlusive disease, or any other condition that puts the patient at high risk, I would not regard complete heart block as an indication for secondary prevention.
DR ANDREW CLARK, senior lecturer and honorary consultant cardiologist, Castle Hill Hospital, Hull
What treatment would you recommend for a woman of childbearing age who has presented with androgenic alopecia? How optimistic can she be about achieving a significant improvement in hair density? What evidence is there about long-term treatment?
Currently, the most effective treatment for female androgenic alopecia is a combination of oral finasteride 5mg daily, together with daily applications of topical minoxidil.
Although they are basically safe, both of these preparations have some problems. Neither is licensed in the UK for this indication and neither is compatible with pregnancy.
Consequently, patients need to be given detailed explanation of their use and treatment should be carried out under specialist supervision.
The main concern is the potential effect of finasteride (a 5-alpha reductase inhibitor) in blocking sexual development of a male fetus. Effective contraception is mandatory.
The choice of oral contraceptive may be important because some progestogens are androgen-derived and may therefore cross-react with the testosterone receptor.
Progestogens that are less androgenic include medroxyprogesterone acetate and norgestimate. Depot injections of medroxyprogesterone acetate may also be used.
Before beginning any form of treatment, underlying diagnoses should also be considered. These include thyroid dysfunction, iron deficiency, autoimmune alopecia and polycystic ovary syndrome.
If a patient wants to become pregnant after her treatment, I would normally stop finasteride and minoxidil at least three months before stopping her contraceptive.
In most patients, clinically significant improvements are seen with finasteride 5mg daily and the 5% topical preparation of minoxidil.
Some patients will notice increased facial and truncal hair growth on this strength of minoxidil, so the dose may have to be reduced to the 2% minoxidil preparation after a few months on the drug. This is at the expense of efficacy.
There is not much data available on long-term use of these drugs in women.
In practice, most patients need one to two years of treatment and report few side-effects. Finasteride has been used extensively in polycystic ovary syndrome and appears very safe.
However, it is advisable that these patients are monitored every six months. There is also a risk of recurrence of hair loss after the course of treatment has been ended.
It is essential to treat any underlying endocrinopathy to prevent the problem recurring.
PROFESSOR SHERN CHEW, consultant endocrinologist and reader in endocrinology at St Bartholomew's and the Royal London Hospitals, and the London Clinic.