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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

Prompt diagnosis and treatment will improve heart failure outcomes

27 Oct 2021Registered users

The majority of new diagnoses of heart failure (HF) are made only after the patient has deteriorated to the point of requiring hospital admission. Within a month of admission with HF, 1 in 4 patients who survive to discharge will be readmitted, and 1 in 8 will die. Ischaemic heart disease is the most common cause of HF, accounting for at least half of diagnoses: following a heart attack, 1 in 3 patients will develop HF within 5 years. Hypertension, diabetes and obesity are also associated with an increased risk of HF.

Detecting and managing atrial fibrillation in primary care

27 Oct 2021Registered users

Atrial fibrillation (AF) is often diagnosed as an incidental finding during a routine medical check. The prevalence increases with age and the presence of CVD further increases the risk of AF. Around 15-30% of patients with AF are asymptomatic. When patients present to their GP the most common symptoms of AF include: palpitations, chest pain, breathlessness and a reduction in exercise/functional capacity. To establish a diagnosis of AF, rhythm documentation with an ECG showing at least 30 seconds of AF is required.

Suspected cardiac syncope requires urgent investigation

27 Oct 2020Registered users

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 2019Registered users

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 2019Registered users

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.

 

Atrial fibrillation

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Registered users

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

Concomitant steroid therapy raises GI bleeding risk in AF patients on DOACs

25 Apr 2022Registered users

Oral glucocorticoids are associated with an increased risk of gastrointestinal bleeding in patients with atrial fibrillation concomitantly treated with direct acting oral anticoagulants, a nationwide study from Denmark has found.

Novel bleeding risk score for atrial fibrillation patients treated with DOACs

25 Mar 2022Registered users

A new, simple risk score for predicting major bleeding in patients with nonvalvular atrial fibrillation treated with direct acting oral anticoagulants (DOACs) has been developed by researchers in Israel.

Sex differences identified in cardiovascular outcomes

24 Jan 2022Registered users

Women who had survived a first coronary event had a significantly lower risk of major adverse cardiovascular events and recurrent coronary heart disease than men, a population-based cohort study has found. However, women had a higher risk of stroke, heart failure, and all-cause mortality compared with men.

Can choice of anticoagulant for AF influence risk of incident dementia?

20 Dec 2021Registered users

Dementia and mild cognitive impairment were less common among patients prescribed direct oral anticoagulants for newly diagnosed atrial fibrillation (AF) compared with those prescribed vitamin K antagonists, in a UK cohort study.

Depression questionnaires fail to reflect patients’ own views of mood changes

20 Dec 2021Registered users

Changes in depression questionnaire scores often disagree markedly with patients’ own ratings of changes in their mood, a prospective cohort study has found.

ECG-based tool aids rapid risk assessment for a cardiac cause of syncope

20 Dec 2021Registered users

In patients with a syncopal event, a combination of seven ECG criteria enabled a rapid assessment of the likelihood that the event was due to a cardiac cause, in a prospective multicentre trial.

Rehabilitation improves physical function in older heart failure patients

25 Sep 2021Registered users

In older patients hospitalised for acute decompensated heart failure an early tailored rehabilitation programme resulted in a greater improvement in physical function compared with usual care together with a reduction in falls and improvement in mood. However, the programme did not result in a significant reduction in readmissions or deaths.

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.

 

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.