The Practitioner - 1868-2012: supporting general practitioners for more than 140 years

The diagnosis of hypertension has traditionally been based on clinic blood pressure (BP) but home and ambulatory measurements are better correlated with cardiovascular outcomes. A recent systematic review and cost-effectiveness study found that ambulatory blood pressure monitoring (ABPM) is more accurate than both clinic and home monitoring in diagnosing hypertension. A diagnostic strategy for hypertension using ABPM, following an initial raised clinic reading, would reduce misdiagnosis and be cost saving for the NHS. This has prompted NICE to update its guidance. 'Currently only about one in every twenty diagnoses is made with an ABPM machine, and these are largely confined to larger GP practices and specialist units. The availability of machines is very limited at present, which could lead to long delays for patients if the guidelines were implemented immediately. Equally critically, any ambulatory machine used should be validated by an appropriate protocol to ensure its accuracy.'

Tailor treatment to the patient in stable angina

19 Oct 2011 Registered users

Stable angina is a chronic condition which may persist for years. It affects a significant proportion of the population, and is more common with advancing age. According to the 2006 Health Survey for England, angina affects 8% of men and 3% of women aged 55-64 increasing to 14% and 8% respectively for men and women aged 65-74. Symptoms of angina can be alarming and distressing and it is therefore important that patients understand the underlying problem and what therapies are available to improve or abolish their symptoms. The management of stable angina in all patients should include appropriate lifestyle changes and optimal medical therapy - and in some patients revascularisation. It is important to reassure patients with clinically significant coronary artery disease, both symptomatic and asymptomatic, that for most a combination of lifestyle modification and optimal medical therapy will prove sufficient treatment. However, a minority of patients may also require intervention either by stents or surgery.

Cardiovascular medicine:Chest pain of recent onset requires prompt diagnosis

23 Jun 2010 Registered users

The new NICE guidance on recent onset chest pain urges GPs to assess the nature and timing of acute pain rapidly and arrange urgent admission for suspected acute coronary syndrome (ACS). Key features of the presenting history are: pain in the chest and/or other areas (e.g. the arms, back or jaw) lasting longer than 15 minutes; chest pain associated with nausea and vomiting, marked sweating breathlessness, or a combination of these; chest pain associated with haemodynamic instability;new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes. If any, or all, of these features are present ACS should be suspected. A 12-lead ECG should be performed and treatment commenced with 300 mg aspirin and GTN spray. Other pain relief such as opiates should be considered. The routine use of oxygen is not advised unless supported by pulse oximetric evidence of desaturation (<94% in those not at risk of hypercapnic respiratory failure).

Cardiovascular medicine: Managing unstable angina and non-ST elevation MI

22 Jun 2010 Registered users

Acute coronary syndrome (ACS), encompassing unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI), is often the result of an acute thrombotic occlusion of the coronary vessels, associated with atheromatous plaque rupture or erosion. ACS is associated with a severely impaired prognosis and requires prompt and efficient specialist treatment. The GP plays a major role in ensuring optimal patient management after hospital discharge and secondary prevention of cardiovascular events.

Cardiovascular medicine: Cardiac rehabilitation should be tailored to the patient

01 Jun 2009 Registered users

The'Care closer to home' initiative in the UK has seen a shift of cardiac rehabilitation services from the hospital to a community setting. Community-based services are preferred by many patients and have been shown to be feasible and effective. The traditional hospital-based programme is divided into four phases. The other widely used model is a six-week, home-based programme using written and audiotape materials. Exercise-based CR results in a 20% reduction in all cause mortality and a 25% reduction in total cardiac mortality.

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Special reports:CVD and stroke

GPs have pivotal role in care of stroke patients

15 Feb 2010 Registered users

GPs play a key role in early recognition of stroke symptoms, thus ensuring that patients receive appropriate acute treatment, early initiation of secondary prevention, lifestyle advice and referral to exercise schemes. It is becoming increasingly recognised that stroke is a chronic disease. So GPs will also be central to managing ongoing risk of recurrent stroke and identifying and managing long-term post-stroke problems.

Identifying patients with the metabolic syndrome

27 Aug 2009 Registered users

The age-adjusted prevalence of metabolic syndrome was approximately 25% of the US adult population in a national survey published in 2002. In a community-based study in the US, the relative risk of developing diabetes over 11 years among obese patients was increased 10-fold in those with the syndrome, and the risk of developing CVD was increased 2-fold. The prevalence of the syndrome in adults in the UK is of the order of 15-20%.

EECP: A non-invasive therapy for refractory angina

01 Feb 2009 Paid-up subscribers

Counter pulsation is a therapy developed from sound physiological principles, widely used in cardiothoracic and interventional centres in the form of intra-aortic balloon pumping (IABP). It has now been developed externally as enhanced external counter pulsation (EECP). EECP is a non-invasive, safe and well tolerated therapy, with very few contraindications. Currently, EECP is used predominantly in patients with severe angina, who are at high risk and are not suitable for revascularisation. It provides a therapeutic and supportive approach to managing such patients regardless of age and co-morbidity including those with stable heart failure.

Rapid assessment vital in stroke and TIA

19 Nov 2008 Registered users

In the 1990s, patients in the UK had a greater risk of stroke-related mortality and disability than elsewhere in Europe. Overall standards have risen.In July 2008 NICE published guidelines for the management of acute stroke and TIA. At the same time, the Intercollegiate Stroke Working Party at the RCP produced guidance covering the rest of the stroke pathway, including secondary prevention, rehabilitation and the management of long-term stroke-related disability.

Guideline will aid early detection of familial hypercholesterolaemia

15 Oct 2008 Registered users

It is estimated that heterozygous FH affects 1 in 500 people in the UK but the vast majority remain undiagnosed, with only 15,000 patients currently identified. It can result in significantly raised LDL cholesterol levels and if left untreated, patients have a high risk of premature CHD, with a >50% risk in men by the age of 50 and >30% in women by the age of 60. If treated early, most patients will have a normal life expectancy.

Clinical Reviews

Is music an effective training aid for CPR?

16 Dec 2011 Registered users

Listening to repeated choruses of Disco Science can improve the rate of chest compressions in subjects carrying out cardiopulmonary resuscitation (CPR) but does not help to achieve the correct depth of compressions, a study has found. Dr Peter Savill reviewed the paper: 'Significantly more delegates maintained compressions within the optimal range of 100 to 120 compressions a minute when listening to Disco Science than when listening to Achy Breaky Heart (82% vs 64%, p=0.07). Achy Breaky was no better than no music (64% vs 65%). However, compressions were still too shallow irrespective of the background music; 39% at the correct depth with Disco Science, 43% with Achy Breaky and 42% with no music. Furthermore, incorrect hand positioning was rife and seen in up to two thirds of delegates. The authors were therefore unconvinced that music provides any benefit in improving the quality of CPR compared with a metronome or audible feedback. Time to abandon iPod augmented CPR then!'

Lowering thromboembolic risk in atrial fibrillation

22 Nov 2011 Registered users

Warfarin consistently lowers the risk of thromboembolism in high-risk patients with atrial fibrillation compared with aspirin and no treatment, a meta-analysis has found.

Are commercial weight loss programmes more effective than standard GP care?

22 Nov 2011 Registered users

Overweight and obese patients who were referred to Weight Watchers lost twice as much weight as those who received standard care in general practice, a study in The Lancet has shown. A total of 772 adults, with a BMI 27-35 kg/m²and at least one additional risk factor for obesity-related disease, were recruited from primary care practices in the UK, Australia and Germany. The study was a parallel group, non-blinded, randomised controlled trial. The authors concluded that a commercial weight loss programme that provides regular weighing, advice about diet and physical activity, motivation, and group support could offer a clinically useful early intervention for weight management in overweight and obese people.

Chest pain characteristics can predict outcome

20 Oct 2011 Registered users

Effort-related pain and two or more episodes of pain in 24 hours are associated with poor outcomes in patients presenting with chest pain of uncertain origin, according to a study, from Spain, in the BMJ. Dr Peter Savill comments:'Patients presenting with chest pain can be a real challenge. Furthermore, an ECG is rarely helpful although often advocated in guidelines. Although this research comes from an acute settingI think the message carries some relevance for primary care physicians as they try to navigate a path through the potential minefield of chest pain.'

Even low levels of moderate exercise reduce risk of CHD

20 Oct 2011 Registered users

Exercising at a moderate intensity for 300 minutes a week is associated with a 20% reduction in CHD risk. Halving this amount of physical activity reduced CHD risk by 14% and a significant risk reduction was also achieved with lower levels of exercise. A meta-analysis was carried out on 33 prospective cohort studies looking at physical activity and primary prevention of CHD, published since 1995. Nine of the studies allowed quantitative estimates of leisure-time physical activity.The researchers found that people who reported the equivalent of 150 minutes per week of moderate-intensity activity had a 14% lower CHD risk, relative risk (RR)=0.86 (95% CI: 0.77-0.96) compared with those reporting no exercise. Those who undertook 300 minutes per week of moderate-intensity activity had a 20% lower risk, RR=0.80 (95% CI: 0.74-0.88). Increasing exercise above 300 minutes per week only produced a modest increase in benefit.

Weighing up the risks and benefits of high-dose statin therapy

20 Sep 2011 Paid-up subscribers

A recent meta-analysis, published in JAMA, has suggested an increase in the risk of developing diabetes with high-dose statin therapy compared with moderate-dose therapy. However, the cardiovascular benefits appear to outweigh the risk of diabetes.The researchers analysed large, randomised controlled, hard end point studies that compared intensive with moderate-dose statin therapy and included more than 1,000 patients followed up for longer than a year. The trials studied in the meta-analysis were PROVE IT-TIMI 22, A to Z, TNT, IDEAL, and SEARCH. These five trials included 32,752 patients without diabetes mellitus at baseline.

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