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.'

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.

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).

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.

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.

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.

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.

Cardiovascular disease (CVD) continues to be the leading cause of mortality, accounting for one in three deaths in England and Wales. In 2005, there were 124,000 deaths attributed to CVD. Around 39,000 of these fatalities were in patients under 75.  multifactorial approach to risk management is of paramount importance to prevention.

The mechanisms of cardiac arrhythmias are complex and recognising these conditions can be difficult. When an arrhythmia is suspected, prompt recording of an ECG is vital, even if symptoms have subsided, as this may be useful for future reference, diagnosis and therapy.

In an average sized practice of 6,000 patients, GPs should expect 12 cases of hypertrophic cardiomyopathy, three cases of nonischaemic dilated cardiomyopathy and one case of arrhythmogenic right ventricular cardiomyopathy.

In some patients chest discomfort may be clearly pleuritic or musculoskeletal in nature and does not require referral. However, in other patients who describe a history of chest discomfort, particularly of recent onset, related to exercise and radiating to the arms and neck, there should be a high suspicion that this represents coronary artery disease.

AF is associated with considerable morbidity and mortality. The mortality rate of patients with AF is approximately double that of patients in normal sinus rhythm. The arrhythmia accounts for 10-15% of all ischaemic strokes, and 25% of ischaemic strokes in patients over 80 years of age. In 2001-2002, the prevalence of AF in Scotland was 8.7 per 1,000, increasing dramatically with age to 71 per 1000 in people aged over 85 years. The prevalence was higher among men. Currently there are an estimated 4.5m people in the European Union with paroxysmal or persistent AF, costing the EU around €13.5 billion per year.¹ This burden is likely to increase as the population ages.

There are a number of ways that patients with AF can be added to the register. These vary in the effort required and the speed of results.

Cardiovascular disease, and in particular coronary heart disease, forms a significant part of the GP workload, and this importance is reflected in the high number of cardiovascular indicators in QOF2. Fortunately, there are also a number of guidelines with clear and robust evidence to underpin our approach to care.