Login:
 

Atrial fibrillation

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.

Prompt diagnosis of AF lowers risk of complications

24 Oct 2016

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.

 

Temporary access

Optimising outcomes in chronic heart failure

22 Feb 2019Paid-up subscribers

Although patients can present with non-specific symptoms and minimal clinical signs, generally, in the community, patients with heart failure present with symptoms of dyspnoea or fluid retention. In order to confirm (or refute) the diagnosis, NICE recommends natriuretic peptide testing (ideally N-terminal pro B-type natriuretic peptide; NT-proBNP) in all patients with suspected heart failure. An NT-proBNP level > 2,000 ng/L is highly suggestive of heart failure and NICE recommends echocardiography and specialist review within 2 weeks. Conversely, an NT-proBNP level < 400 ng/L suggests that a diagnosis of heart failure is unlikely. Patients with an NT-proBNP of 400-2,000 ng/L should have echocardiography and specialist assessment within 6 weeks.

 

Cardiovascular Symposium

Managing stable angina in primary care

22 Oct 2018Paid-up subscribers

Around 50% of people diagnosed with ischaemic heart disease present with stable angina as the first symptom. The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors present. A resting 12-lead ECG is recommended for all patients with suspected angina. However, a normal result does not exclude the presence of underlying coronary artery disease.

Tracking down and treating the cause of syncope

22 Oct 2018Registered users

Syncope is a transient loss of consciousness (T-LOC) caused by cerebral hypoperfusion, characterised by a rapid onset, short duration and spontaneous complete recovery. It needs to be differentiated from other conditions that can cause T-LOC such as seizures, trauma, hypoglycaemia, and psychogenic causes. Three principal types of syncope can be identified: reflex or neurally mediated, orthostatic hypotensive and cardiac. The common denominator of all these conditions is low systemic BP causing global cerebral hypoperfusion.

Improving uptake of cardiac rehabilitation

23 Oct 2017Registered users

Data from the National Audit of Cardiac Rehabilitation show that 50% of eligible MI, PCI, and CABG patients do attend cardiac rehabilitation and that figure continues to rise, but the rates for stable angina and heart failure remain low. There is evidence that programmes which have a basis in psychoeducation (goal setting, self-monitoring, relapse prevention) are more likely to achieve long-term behaviour change than those based simply on delivering a fixed agenda of exercise and education. A recent Cochrane review of exercise-based cardiac rehabilitation continues to show the benefit of exercise prescription in terms of cardiovascular mortality, hospital readmission rates, and quality of life.

Assessment and management of CVD risk in adults

23 Oct 2017Registered users

Cardiovascular disease (CVD) affects seven million people in the UK alone. Modifiable risk factors for CVD include smoking, abnormal lipid profile, hypertension, diabetes, abdominal obesity, psychosocial factors, diet, alcohol consumption, and lack of physical activity. The INTERHEART study concluded that these factors account for more than 90% of the risk of MI worldwide. Well validated studies have suggested that QRISK2 is a better predictor of a patient’s ten-year risk of CVD compared with the traditionally used Framingham equation.

Prompt diagnosis of AF lowers risk of complications

24 Oct 2016

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.

Early recognition vital in acute coronary syndrome

24 Oct 2016Registered users

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.

 

Children and adolescents

Diagnosing heart disease in children and adolescents

22 Jun 2017Paid-up subscribers

Heart disease in children and adolescents can be congenital, in which structural defects of the heart and major blood vessels are present from birth, acquired, whereby disease develops during life, or genetic, including diseases affecting the heart muscle, electrical system or the aorta. The incidence of congenital heart disease has decreased over the past 30 years, with approximately 1 in 180 babies born with congenital heart disease in the UK each year. Several cardiac diseases are genetic and can manifest in childhood. Most are primary cardiomyopathies, ion channel diseases, coronary artery disease from familial hypercholesterolaemia or aortopathies.

 

Women and cardiovascular risk

Underestimating risk in women delays diagnosis of CVD

21 Mar 2016Paid-up subscribers

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.

 

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

Tailor BP targets to the older patient with hypertension

25 Jun 2018Paid-up subscribers

The prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

Timely diagnosis of heart failure can improve prognosis

28 Jul 2017Paid-up subscribers

Heart failure is a common, complex clinical syndrome resulting from the impaired ability of the heart to cope with the metabolic needs of the body, leading to breathlessness, fatigue and fluid retention. It is a progressive disease characterised by high levels of morbidity and mortality. Measuring plasma levels of natriuretic peptides is recommended for ruling out heart failure, as patients with normal levels are unlikely to have heart failure. An echocardiogram is indicated if the natriuretic peptides are elevated, or natriuretic peptide testing is not available.

Erectile dysfunction heralds onset of cardiovascular disease

23 Jun 2016Registered users

Erectile dysfunction (ED) has been shown to share risk factors with cardiovascular disease including age, diabetes mellitus, smoking, hypertension and hypercholesterolaemia, suggesting an underlying vascular pathology. Evidence reveals that there is a potential link between ED and subsequent development of coronary artery disease. ED itself may also increase cardiovascular risk. As ED often predates the development of coronary artery disease this provides GPs with a valuable window of opportunity for risk assessment, subsequent primary prevention and early referral to a cardiologist.

Can my patient with CVD travel to high altitude?

25 Apr 2013Paid-up subscribers

Patients with borderline health should consult a physican before travelling to altitude. The physician will need to know the duration of the trip, ascent profile and how much exercise the patient plans to undertake. The presence of comorbid diseases which reduce oxygenation and ventilation should also be taken into account. Every patient must be assessed on an individual basis, there are no clinical investigations which reliably predict outcome at altitude. Patients should not travel to high altitude immediately after an acute coronary syndrome. Most patients with stable coronary artery disease with a sufficiently high exercise capacity at sea level can go as high as 3,000–3,500 m with only a minimally increased risk.

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.

Time to encourage patients to take more exercise

20 Sep 2012Paid-up subscribers

London has just played host to possibly the greatest ever Olympic and Paralympic Games. I enjoyed my small part as a medical volunteer at the Olympic football tournament. Numerous public figures have talked about the potential legacy promoting sport and exercise to the population. This could also be the greatest opportunity for GPs and sport and exercise medicine specialists in the UK to combine forces to deliver our strongest ever campaign to promote physical activity and improve the nation’s health.

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.

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.
 

Research Reviews by GP with special interest

Bundle branch block an indicator of heart failure risk

25 Sep 2019Paid-up subscribers

Opportunistic finding of bundle branch block (BBB) in primary care patients without major cardiovascular disease should be considered a warning of future heart failure, a retrospective cohort study from Denmark concludes.

How does weight change affect risk of atrial fibrillation?

07 Aug 2019Paid-up subscribers

Putting on weight appears to raise the risk of developing atrial fibrillation (AF), a meta-analysis  by investigators in Oxford, UK, has concluded. However, no clear evidence emerged as to whether weight loss reduces the risk.

Sitting time linked to raised mortality risk in inactive adults

22 May 2019Paid-up subscribers

Sitting for long periods is associated with an increased risk of all cause and cardiovascular disease (CVD) mortality among the least physically active adults. However, moderate to vigorous physical activity equivalent to public health recommendations can attenuate or effectively eliminate such associations, a study from Australia has found.

Continuous ECG vs loop recording for AF detection post stroke

24 Apr 2019Registered users

Automatic external loop recording (ELR) is not suitable as a single monitoring device for AF screening following stroke, a prospective cohort study from Denmark has concluded.

Cuffless vs standard devices for ambulatory blood pressure monitoring

25 Mar 2019Registered users

A novel cuffless device recorded significantly higher values for both systolic and diastolic blood pressure (BP) compared with standard equipment for 24-hour ambulatory BP monitoring, in a small study from Switzerland.

Reminder app improves compliance with CHD therapy

22 Feb 2019Registered users

The use of a widely available basic medication reminder app significantly improved adherence to treatment for coronary heart disease (CHD), in a study from Australia.

High BP, smoking and diabetes are stronger predictors of MI in women than men

20 Dec 2018Registered users

Hypertension, smoking, especially heavy smoking, and both type 1 and type 2 diabetes are associated with a higher risk of myocardial infarction (MI) in women than men, a prospective population-based study has shown.

AF recurrence following catheter ablation more likely in obese patients

22 Nov 2018Registered users

Atrial fibrillation (AF) patients with a baseline BMI = 30 kg/m2 have a higher recurrence rate following catheter ablation, a  study of  an AF Ablation Long-Term Registry that included 104 centres across 27 European countries.

Pre-eclampsia raises risk of vascular dementia later in life

22 Nov 2018Registered users

Women with a history of pre-eclampsia are three times more likely to develop vascular dementia later on, a Danish cohort study has found.

New antiplatelet agents are more effective in preventing recurrent MI

22 Oct 2018Registered users

Compared with clopidogrel, prasugrel and, in particular ticagrelor, led to a significant reduction in risk of recurrent fatal and non-fatal myocardial infarction (MI) in patients with acute coronary syndrome (ACS), in a study from France.

Length and quality of sleep may affect cardiovascular risk

24 Sep 2018Registered users

Sleeping for more than 8 hours a night was associated with an increased risk of mortality and poor quality sleep with an increased risk of coronary heart disease (CHD), a large meta-analysis has found.

Raised resting heart rate associated with increased mortality risk

25 Jul 2018Registered users

A high resting heart rate and an increase in resting heart rate over a decade are associated with a greater risk of death from cancer and other causes as well as cardiovascular disease (CVD), a study from Australia has found.

 

Antiplatelet & anticoagulant research reviews

New antiplatelet agents are more effective in preventing recurrent MI

22 Oct 2018Registered users

Compared with clopidogrel, prasugrel and, in particular ticagrelor, led to a significant reduction in risk of recurrent fatal and non-fatal myocardial infarction (MI) in patients with acute coronary syndrome (ACS), in a study from France.

Anticoagulants underused in older heart failure patients with AF

27 Feb 2018Registered users

Overestimation of risk of bleeding leads to underuse of oral anticoagulants in frail elderly heart failure patients with atrial fibrillation (AF) despite their increased risk of stroke, a study in Heart has concluded.

Triple antiplatelet therapy no better than standard regimens after ischaemic stroke

23 Jan 2018Registered users

Intensive antiplatelet therapy with three agents did not reduce the incidence and severity of recurrent stroke or transient ischaemic attack (TIA) but did significantly increase the risk of major bleeding in the TARDIS study.

Clopidogrel vs aspirin in patients with drug-eluting stents

22 Feb 2016Registered users

Monotherapy with clopidogrel was associated with a reduced risk of recurrent ischaemic events compared with aspirin in patients with drug eluting stents (DES), in an observational study. All patients had previously undergone 12 months of dual antiplatelet therapy following stent insertion.

New oral anticoagulants have a good risk-benefit profile in atrial fibrillation

24 Feb 2014Paid-up subscribers

The new oral anticoagulants are at least as good as, if not better than, warfarin at preventing strokes in patients with atrial fibrillation and have a lower rate of major bleeding, a large meta-analysis has found. The analysis, published in The Lancet, covered trials of atrial fibrillation patients who were randomised to new oral anticoagulants or warfarin, and in which both efficacy and safety outcomes were reported. A total of 71,683 patients in the RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI 48 trials were included.

 

Editorials

Is exercise as effective as drug therapy in reducing systolic BP?

23 Jan 2019Paid-up subscribers

The systolic blood pressure lowering effect of endurance or dynamic resistance exercise among hypertensive populations appeared similar to that of commonly used antihypertensive medications (ACE inhibitors, angiotensin-2 receptor blockers, beta-blockers and diuretics) in a network meta-analysis.

Fish oil supplements fail to lower cardiovascular risk in diabetes

22 Nov 2018Registered users

Dietary supplementation with n-3 fatty acids (fish oils) in patients with diabetes is not associated with a reduction in cardiovascular events, a large randomised controlled study has found.  ‘These findings, together with results of earlier randomised trials involving patients with and those without diabetes, do not support the current recommendations for routine dietary supplementation with n-3 fatty acids to prevent vascular events,’ the study authors conclude.

GP auscultation a poor predictor of valvular heart disease

25 Jun 2018Paid-up subscribers

Auscultation has only limited accuracy in the detection of valve disease in asymptomatic patients and is a poor diagnostic screening tool in primary care, a UK study has found.

Smoking just one cigarette a day raises risk of CHD and stroke

22 Feb 2018Registered users

Smoking one cigarette per day carries a risk for cardiovascular disease of around half that of those who smoke 20 per day, a systematic review and meta-analysis has found.

Bariatric surgery cuts admissions in obese patients with angina

23 Nov 2017Registered users

In obese adults with stable angina, the rate of hospitalisation for the condition was reduced by two-thirds after bariatric surgery, in a case series study from the United States.  The rate remained lower for at least two years.

Patients with paroxysmal AF at risk of stroke are undertreated

23 Oct 2017Registered users

Patients with paroxysmal atrial fibrillation (AF) eligible for anticoagulation are still less likely to receive anticoagulants than those with persistent or permanent AF, a UK study has found. Both national and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of the type of AF. Even in 2015 patients with paroxysmal AF eligible for anticoagulation were still almost 20% less likely to have these drugs prescribed than those patients with persistent or permanent AF.

Does metformin lower CVD risk in type 2 diabetes?

28 Sep 2017Registered users

A recent meta-analysis to evaluate the impact of metformin on cardiovascular disease has been unable to demonstrate convincingly that it is associated with a reduction of risk. The investigators searched Medline, Embase and the Cochrane Library for relevant papers in all languages.  The final yield was ten articles, reporting 13 trials of metformin, virtually all carried out in Northern Europe or North America. In total, 2,079 patients with type 2 diabetes were allocated to metformin and a similar number to comparison groups. All the outcomes, with the exception of stroke, favoured metformin but none achieved statistical significance.

PPIs with aspirin in older patients lowers risk of major bleeds

28 Jul 2017Registered users

A UK prospective population-based cohort study assessed the risk, time course, and outcomes of bleeding on antiplatelet treatment for the secondary prevention of cardiovascular disease in patients of all ages. The authors concluded that in secondary prevention with aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of bleeding at age 75 years or older is higher and more sustained than in the younger age groups included in previous trials, with particularly high risks of disabling or fatal upper GI bleeding. 'Given that half of the major bleeds in patients aged 75 years or older were upper GI, the estimated NNT for routine PPI use to prevent major upper GI bleed is low and co-prescription should be considered in future secondary prevention guidelines,' they say.

Risk of acute STEMI significantly increased in younger smokers

23 Jan 2017Registered users

Smoking is associated with an eight-fold increased risk of acute ST-segment elevation myocardial infarction (STEMI) in those under 50 compared with former and never smokers, a UK study has found.

Antidepressants and cardiovascular risk

23 May 2016Registered users

Selective serotonin reuptake inhibitors are not associated with an increased risk of cardiovascular events in younger adults with depression, a large UK cohort study has found.