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Women and cardiovascular risk

Underestimating risk in women delays diagnosis of CVD

21 Mar 2016Registered users

CVD remains the most common cause of mortality in women. There has been an increase in the prevalence of MI in women aged 35 to 54, while a decline in prevalence was observed in age-matched men. Although men and women share classic cardiovascular risk factors the relative importance of each risk factor may be gender specific. The impact of smoking is greater in women than men, especially in those under 50. Diabetes is a more potent risk factor for fatal CHD in women than men.

Women with diabetes at greater risk of CHD than men

23 Jun 2014Registered users

A recent large meta-analysis has confirmed that women with diabetes have more than a 40% higher risk of incident coronary heart disease (CHD) than men. For GPs this is a timely reminder to consider CHD as a high risk in women with diabetes, and to treat risk factors vigorously. This is especially important because routine screening in the healthy population accustoms us to women being generally at lower risk than men using the current CHD risk tools.

MI often presents without chest pain in women

21 Mar 2012Paid-up subscribers

The textbook presentation of myocardial infarction (MI) is not difficult to recognize but in the undifferentiated world of primary care presentations it can be far from clear. This difficulty is compounded by the sex and ethnicity of the patient and the presence of comorbidities such as diabetes. Women are often older than men at hospitalisation for MI and present less frequently with chest pain. It is generally accepted that patients without chest pain tend to present later and are treated less aggressively than those presenting with more typical symptoms. Furthermore, those presenting without pain have almost twice the short-term mortality rate.

 

Cardiovascular Symposium

Early recognition vital in acute coronary syndrome

24 Oct 2016

Acute coronary syndrome (ACS) includes both ST (STEMI) and non ST elevation (NSTEMI) MI, and unstable angina. Patients with ACS typically present with chest pain; classically central chest pain that radiates to the left arm. Additional symptoms include dyspnoea, nausea, sweating and syncope. However, patients can present atypically with gastric symptoms. These are often more common in patients with diabetes, women and the elderly. A 12-lead ECG should be performed if possible within 10 minutes of presentation or ideally at first contact with the emergency services.

Prompt diagnosis of AF lowers risk of complications

24 Oct 2016Paid-up subscribers

Estimates suggest an AF prevalence as high as 2% in adults with an exponential relationship with increasing age. Opportunistic screening for silent AF is recommended in at-risk groups. AF is associated with a 1.5-2 fold increased risk of death, and is responsible for 20-30% of all strokes. The CHA2DS2-VASc risk stratification score is recommended to assess stroke risk in patients with AF. Risk of severe bleeding with warfarin should also be assessed using the HAS-BLED score.

Management of heart failure with preserved ejection fraction

21 Oct 2015Paid-up subscribers

Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpEF). Newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise. Patients are likely to be older women with a history of hypertension. Other cardiovascular risk factors, such as diabetes mellitus, atrial fibrillation and coronary artery disease are prevalent in the HFpEF population.

Playing it safe:exercise and cardiovascular health

21 Oct 2015Registered users

Regular physical activity controls acquired cardiovascular risk factors such as obesity, diabetes mellitus, hypertension and hyperlipidaemia. Exercise is generally associated with a 50% reduction in adverse events from coronary artery disease. Active individuals are at lower risk of developing certain malignancies including cancer of the prostate and the colon, osteoporosis, depression and dementia. Individuals who exercise regularly extend their life expectancy by three to seven years. Healthy individuals should engage in 150 minutes of moderate-intensity aerobic exercise per week. Even lower volumes of exercise confer health benefits, which is highly relevant to individuals with established cardiac disease including heart failure.

Diagnosis and management of inherited cardiomyopathies

23 Oct 2014Paid-up subscribers

Inherited heart conditions are the most common cause of sudden cardiac death in those under the age of 35 and the leading cause of non-traumatic death in young athletes. In many cases the first manifestation of an inherited cardiomyopathy can be a sudden cardiac arrest. Other presentations include chest pain or breathlessness during exertion, palpitations and syncope. Hypertrophic cardiomyopathy is the most common inherited heart disease affecting 1 in 500 of the population. Some patients may exhibit severe left ventricular hypertrophy, others may show nothing more than an abnormal ECG.

 

Clinical Reviews

Drinking tea every day may lower risk of ischaemic heart disease

22 Jun 2017Registered users

Daily tea consumption was associated with an 8% relative risk reduction in ischaemic heart disease and a 10% relative risk reduction in major cardiac events, in a large prospective study from China.

Heavy drinkers and teetotallers at increased risk of wide range of cardiovascular diseases

23 May 2017Registered users

Both high levels of alcohol consumption and abstinence raise the risk of a broad spectrum of cardiovascular disorders, a UK study has shown.

Non-major bleeds less frequent in AF patients on apixaban

23 May 2017Paid-up subscribers

Non-major bleeding was substantially less in patients on apixaban compared with those on warfarin in the Apixaban for Reduction in Stroke and other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. 

Stress echo has good diagnostic accuracy in elderly patients

24 Apr 2017Paid-up subscribers

Stress echocardiography is a safe and effective first-line test for suspected coronary artery disease in patients over 80, a UK study, published in Heart, has found.

 

Respiratory/cardiovascular symposium articles

Diagnosing and managing pulmonary hypertension

12 Dec 2012Paid-up subscribers

Pulmonary hypertension (PH) is defined as an increase in mean pulmonary arterial pressure ≥ 25 mmHg at rest as assessed invasively by right heart catheterisation. It can affect patients at any age and presents with non-specific symptoms. Accurate diagnosis is important as while PH is a potentially lethal disease it is treatable. Identification of the cause of PH is crucial to ensure that the patient receives appropriate management.

 

Special reports:CVD and stroke

Improving identification and treatment of atrial fibrillation

12 Dec 2012Paid-up subscribers

Atrial fibrillation is the most common sustained cardiac arrhythmia. One in 40 of the over 45s, 1 in 20 of the over 65s, 1 in 10 of the over 75s and 1 in 5 of the over 85s will have paroxysmal, persistent or permanent atrial fibrillation. Although many individuals will have idiopathic atrial fibrillation with otherwise healthy hearts and no comorbidities, its development is associated with a number of common risk factors. Every patient with a diagnosis of atrial fibrillation should have a physical examination to assess blood pressure and look for signs of valve disease and heart failure. It is routine to check thyroid function and NICE guidelines recommend echocardiographic assessment.

Recent developments in the management of heart failure

20 Jun 2012Paid-up subscribers

Because it can be difficult to diagnose heart failure correctly, NICE has given specific advice in its guideline, issued in 2010. In 2012, any patient with suspected heart failure should have the diagnosis confirmed or refuted rapidly, with onward referral for echocardiography and specialist assessment. GP access to BNP/NTproBNP testing is vital to do this effectively. The GP is key to this process – acting as the patient’s advocate for timely diagnosis, making sure drug therapy is introduced and optimised, monitoring the patient’s condition, and identifying when the plan needs to be modified. With access to good diagnosis and good treatment the prognosis of this condition has improved remarkably in the past 20 years but without such modern therapy the syndrome can still be a death sentence.

Targeting CVD risk in chronic connective tissue disease

24 Jan 2012Paid-up subscribers

Chronic inflammatory rheumatological conditions are associated with an increased burden of cardiovascular disease (CVD). In both rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) most excess mortality is cardiovascular. The prevalence of subclinical disease indicates that the atherogenic processes start early in the course of inflammatory disease. Although less data are available regarding the extent of the problem in other inflammatory arthritides or connective tissue diseases, increased CVD risk is also associated with psoriatic arthritis, ankylosing spondylitis, antiphospholipid syndrome and systemic sclerosis. Management of CVD risk in these patient groups is hampered by the complexity of both the underlying disorder and its treatment, and by the lack of clear guidelines for either primary or secondary care teams.

Improving the management of chronic heart failure

24 Nov 2010Paid-up subscribers

NICE has updated its guideline on the management of chronic heart failure. The principal changes from the 2003 guideline include more directive advice on how to improve the quality and timeliness of diagnosis. There is greater encouragement to use beta-blockers, more emphasis on rehabilitation and better access to specialist advice - particularly at the time of diagnosis, admission to hospital, and where symptoms do not respond to first-line therapy with diuretics, ACE inhibitors and beta-blockers. 'A new recommendation is that patients with stable heart failure should be offered a supervised group exercise-based rehabilitation programme designed for such patients. 

GPs have pivotal role in care of stroke patients

15 Feb 2010Paid-up subscribers

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 2009Paid-up subscribers

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 2009Paid-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.
 

Editorials

Statins underused for primary prevention in older patients

19 Sep 2012Paid-up subscribers

'A treatment-risk paradox where patients become less likely to receive appropriate treatment with advancing age has been observed in the secondary prevention of cardiovascular disease (CVD). This is particularly apparent for cholesterol-lowering treatment with one study showing the likelihood of statin treatment was 6% lower with each year increase in age. However, it is not clear if such a paradox exists in primary prevention and a recent UK study published in the BMJ addresses this issue...'

Reducing deaths from smoking

23 May 2012Paid-up subscribers

There are around 10 million smokers in the UK, half of whom will die prematurely, losing many years of life, unless they quit. Smoking is increasingly concentrated in the most disadvantaged sectors of society, and is now the biggest avoidable cause of social inequality in life expectancy in the UK. Preventing smoking depends on reducing the affordability of cigarettes, using the media to educate and promote health, making non-smoking the norm in public and workplaces, preventing advertising and promotion, preventing supply to children, and providing effective support to individuals who want to quit.

Time to tackle obesity

16 Dec 2011Registered users

It is estimated that almost a quarter of the population of England are obese. Primary care physicians are familiar with the subsequent problems that can arise such as diabetes, cardiovascular disease and osteoarthritis to list but a few. At present the Quality and Outcomes Framework places little emphasis on obesity management and there are few options available in traditional models of primary care. There is certainly evidence to support the notion of centrally funded commercial weight loss programmes. Another option is for primary care teams to develop in-house obesity management programmes. Dr Peter Savill looks at recent evidence on the effectiveness of such options for treatment.

Strokes have declined but atrial fibrillation is still undertreated

22 Nov 2011Paid-up subscribers

Stroke is a major cause of morbidity and mortality. Primary care has a central role to play in prevention with the identification and management of hypertension, obesity, high cholesterol, atrial fibrillation (AF) and diabetes. A recent study has found that both the incidence of stroke and stroke deaths declined significantly over the past decade in the UK. This was accompanied by a notable increase in GP prescribing for primary and secondary prevention which is likely to have been a major contributing factor, the study authors conclude. However, the study also found underuse of anticoagulants in patients with AF at high risk of stroke, particularly in women.

 

SI Cardiovascular PDF collections

Special Interest - Cardiovascular medicine 2: Main articles published in 2012

07 Feb 2013Paid-up subscribers

Key articles on cardiovascular disease plus clinical reviews from 2012 issues of The Practitioner. This PDF pack can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.

  • Identifying patients at risk of sudden arrhythmic death
  • Early diagnosis of peripheral arterial disease can save limbs
  • Rapid diagnosis of TIA reduces risk of subsequent stroke
  • Diagnosis and managing pulmonary hypertension
  • Recent developments in the management of heart failure
  • Improving identification and treatment of atrial fibrillation

Special interest - Cardiovascular medicine 1 (July-October 2012)

14 Nov 2012Paid-up subscribers

Key articles on cardiovascular disease plus clinical reviews from the July to October 2012 issues of The Practitioner. This PDF pack can be saved directly into your personal development plan folder on your computer or for review in the PDF reader on your tablet computer.