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Special reports

Diagnosis and management of hypertension in primary care

24 Feb 2020Registered users

NICE stipulates that two of the following are required for the diagnosis of hypertension: clinic blood pressure (BP) 140/90 mmHg or higher and ambulatory BP monitoring daytime average or home BP monitoring average 135/85 mmHg or higher. Evaluation of newly diagnosed hypertension includes an assessment of underlying cardiovascular disease (CVD) risk and target organ damage. Treatment threshold varies with underlying risk. For those at lower risk (< 10% risk of a CVD event over 10 years), drug treatment is not recommended below 160/100 mmHg.

Detecting and managing pulmonary hypertension

20 Dec 2019Registered users

Pulmonary hypertension (PH) is a haemodynamic state where the mean pulmonary artery pressure measured at cardiac catheterisation is 25 mmHg or more. Precapillary PH arises from increased resistance to blood flow in the pulmonary arterioles and postcapillary PH from elevated left atrial pressure. In postcapillary PH the cause is left heart disease whereas precapillary PH may be caused by any other form of PH. Patients develop symptoms only when the disease is advanced. Symptoms at presentation are non specific. Adults almost always present with breathlessness and may also complain of exercise-induced dizziness or syncope and angina. An echocardiogram is the best investigation to ascertain the probability of PH.

 

Cardiovascular Symposium

Suspected cardiac syncope requires urgent investigation

27 Oct 2020Paid-up subscribers

Around 40% of people experience a syncopal event during their lifetime. Cardiac syncope accounts for 10% of presentations. Incidence rises significantly with age. Assessment should be systematic: a thorough history, physical examination including lying and standing BP and 12-lead ECG. The medical history and physical examination are key. If following initial assessment cardiac syncope is suspected patients should be referred for urgent specialist cardiovascular assessment or emergency admission.

Diagnosis and management of abdominal aortic aneurysm

27 Oct 2020Registered users

Risk factors for abdominal aortic aneurysm formation include: smoking, increasing age, and family history. Men over the age of 65 are most commonly affected, with an abdominal aortic aneurysm present in approximately 1%. As the condition is normally asymptomatic, most patients have their aneurysms discovered through the screening programme or incidentally via other imaging investigations. Patients with a new diagnosis of an abdominal aortic aneurysm should be referred to their local vascular service.

More patients could benefit from referral for cardiac rehabilitation

25 Nov 2019Paid-up subscribers

Cardiac rehabilitation is a combination of medical and behavioural interventions designed to facilitate recovery and prevent future cardiovascular disease events. A cardiovascular prevention and rehabilitation programme (CPRP) is a critical element within the management pathway for most patients with heart disease and has a particularly strong evidence base for those with either symptomatic atherothrombotic vascular disease or heart failure. Following acute MI and/or coronary revascularisation, attending and completing a CPRP is associated with an absolute risk reduction in cardiovascular mortality from 10.4% to 7.6%.

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Paid-up subscribers

Stroke is the most debilitating complication of atrial fibrillation (AF). AF-related strokes account for 20-25% of all strokes and are generally more severe and disabling and more likely to recur. Oral anticoagulation (OAC) remains the cornerstone of AF management with a clear prognostic benefit. It reduces stroke risk by two-thirds and mortality by a quarter. The decision to anticoagulate is taken irrespective of the pattern and duration of AF (paroxysmal, persistent or permanent). A large evidence base supports the use of OAC in men with a CHA2DS2-VASc score of 2 or more and women with a score of 3 or more. Hence, in the absence of absolute contraindications, OAC is strongly recommended.

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.

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.

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.

 

Atrial fibrillation

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Paid-up subscribers

Stroke is the most debilitating complication of atrial fibrillation (AF). AF-related strokes account for 20-25% of all strokes and are generally more severe and disabling and more likely to recur. Oral anticoagulation (OAC) remains the cornerstone of AF management with a clear prognostic benefit. It reduces stroke risk by two-thirds and mortality by a quarter. The decision to anticoagulate is taken irrespective of the pattern and duration of AF (paroxysmal, persistent or permanent). A large evidence base supports the use of OAC in men with a CHA2DS2-VASc score of 2 or more and women with a score of 3 or more. Hence, in the absence of absolute contraindications, OAC is strongly recommended.

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.

 

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

Management of hypertensive disorders in pregnancy

07 Aug 2019Paid-up subscribers

Hypertension is the most common medical complication of pregnancy, affecting 8-10% of pregnancies in the UK. It is associated with risks to both the woman and the fetus, with increased risks of pre-eclampsia, preterm delivery, fetal growth restriction, placental abruption and perinatal death. Any new onset of hypertension after 20 weeks or symptoms or signs suspicious of pre-eclampsia should be referred for same day assessment at a secondary care antenatal assessment unit.

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.

 

Research Reviews by GP with special interest

Raised NT-proBNP predicts poor outcomes in AF without heart failure

25 May 2021Registered users

High NT-proBNP levels appear to be an independent predictor of adverse outcomes in patients with atrial fibrillation (AF) in the absence of heart failure, a study from Japan has found. Raised NT-proBNP levels were significantly associated with higher incidences of stroke/systemic embolism, all-cause death and hospitalisation for heart failure during a median follow-up period of five years.

Recreational substance use raises risk of early onset CVD

22 Apr 2021Registered users

Use of illicit drugs, as well as tobacco and alcohol, is associated with an increased risk of premature atherosclerotic cardiovascular disease (CVD), especially in women, a study from the US has shown. Those with multiple substance use had a graded response with the highest risk of premature CVD among individuals who used four or more recreational substances.

Sex differences remain in the prevalence and treatment of CVD risk factors

22 Mar 2021Registered users

Differences persist in the prevalence, treatment and control of risk factors for cardiovascular disease between men and women, an analysis of data from the Health Survey for England 2012-2017 has found. Men were more likely to have one or more risk factors than women. However, figures for both treatment and control of dyslipidaemia were significantly lower in women than men.

Which drugs should be used first line for hypertension?

21 Feb 2021Registered users

Tailoring choice of antihypertensives to the patient rather than using strict age criteria might be more beneficial, the authors of a UK observational cohort study suggest.

Childhood cancer survivors at increased risk of cardiac ischaemia

25 Jan 2021Registered users

Children who have survived cancer, particularly those treated with chemotherapy and/or radiotherapy, have a higher risk of adverse cardiac events later on, a pan-European study has found.

Can a hot bath a day keep the cardiologist away?

21 Dec 2020Registered users

Taking a hot bath every day or most days may lower the risk of cardiovascular disease (CVD), a study from Japan has suggested.

Loneliness a risk factor for cardiovascular disease

24 Sep 2020Registered users

Loneliness but not social isolation appears to be an independent risk factor for cardiovascular disease, an analysis of data from the English Longitudinal Study of Ageing suggests.

Lifestyle intervention reduces risk factors in older patients with coronary artery disease

24 Jul 2020Registered users

Patients aged 65 years and over with coronary artery disease benefitted at least as much as younger patients in improving lifestyle risk factors in a community-based trial from the Netherlands. Older patients were more likely to achieve the weight loss target and stop smoking.

Abdominal obesity post MI raises risk of recurrent MI or stroke

25 May 2020Paid-up subscribers

Abdominal obesity is an independent risk factor for a further myocardial infarction (MI) or stroke in patients who have already suffered a first MI, an observational cohort study from Sweden has shown. A total of 22,882 MI patients from the SWEDEHEART registry (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) were recruited to the study.

Exercise improves function and mortality rates in older patients following ACS

23 Apr 2020Paid-up subscribers

A largely home-based exercise intervention improved grip strength, mobility, daily activities and quality of life in older patients after acute coronary syndrome, an Italian study has shown. Hospitalisation and death rates were also reduced by the intervention. A total of 235 patients, median age 76 years, range 73-81 years, were recruited to the trial conducted at three sites in Italy. They were randomised one month after their ACS event to the exercise or control group. All had reduced physical performance defined by the short physical performance battery with scores of 4-9.

Are psychological techniques effective in patients at high risk of CVD?

24 Mar 2020Paid-up subscribers

Enhanced motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in patients at high risk of cardiovascular disease, a primary care study has shown.

How accurate are wearable electronic devices for monitoring atrial fibrillation?

24 Feb 2020Paid-up subscribers

A smartwatch-based patient device demonstrated only moderate diagnostic accuracy in detecting atrial fibrillation (AF) when compared with a 12-lead ECG, in a study from Australia. Accuracy was improved if the automated device diagnosis was combined with specialist interpretation of unclassified tracings.

 

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.