The Practitioner - 1868-2010: supporting general practitioners for 140 years

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 Paid-up subscribers

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: Managing familial hypercholesterolaemia

01 Jun 2009 Registered users

Familial hyper-cholesterolaemia (FH) is a relatively common genetic disorder. The heterozygous form affects 1 in 500 people in the UK, i.e. 0.2% of the population. However, the vast majority of patients remain undiagnosed. FH is a risk factor for the development of premature atherogenesis. All first-degree relatives, not just the children, of FH patients have a 50% risk of having the condition; and should be traced and tested, a process known as cascade testing. Until such services become widely available, the BHF has recommended that, relatives of a patient with FH should be advised to visit their GP to be evaluated and, preferably, referred for a DNA test.

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.

GPs have pivotal role in managing CHF

18 Jun 2008 Registered users

Chronic heart failure (CHF) is a common syndrome of breathlessness and fatigue in the presence of left ventricular (LV) dysfunction. Its prevalence increases with age, reaching 10% in patients >80 years. Despite advances in medical and device therapies, patients with CHF still have frequent readmissions to hospital and an annual mortality rate approaching 10-15% per year.

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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 Registered users

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

Folic acid plus B12 does not improve CVD outcomes in high-risk patients

20 Jul 2010

Lowering homocysteine levels with folic acid and vitamin B12 supplements does not reduce the risk of cardiovascular events or stroke in patients who have suffered an MI, a major study has concluded. it would appear that SEARCH has finally laid the homocysteine theory to rest. Raised levels may be associated with increased cardiovascular risk but this would not appear to be a causal association. The authors also noted that a recently submitted meta-analysis of individual patient data from eight homocysteine lowering trials, including SEARCH, with data on 37,485 individuals, confirms that folic acid supplementation has no significant effect on major vascular events, RR 1.01 (95% CI: 0.97-1.05).

Optimal medical therapy boosts one-year survival rates following acute MI

24 Jun 2010 Registered users

One-year mortality following MI can be significantly improved by giving patients a combination of five drug classes: aspirin, beta-blockers, statins, renin angiotensin system (RAS) blockers and thienopyridines. However, less than half of patients receive this optimal therapy, a study from Germany has shown. 'These findings should further reinforce our efforts to maximise the uptake of these drugs in our post-infarct populations. This should form a key part of cardiac rehabilitation and primary care chronic disease programmes.'

Does chocolate lower CVD risk?

19 May 2010

'I think we still need a randomised controlled trial of flavanol-rich chocolate but in the meantime it would seem that a little bit of chocolate is good for you. Don't get carried away though as those in the highest quartile only consumed 7.5g a day which is equivalent to a small square. A 100g bar has around 500 calories and a fair bit of that is sugar. So everything in moderation.'