Treating Hypertension in Elderly Patients

Patients of all ages should be treated to target when it comes to hypertension. The NICE guidelines on Hypertension (NG136) recommend a clinic blood pressure (BP) of less than 150/90 mmHg for patients over the age of 80. For patients over 55, calcium channel antagonists are the most appropriate first-line therapies, unless there is evidence of oedema, heart failure, or the patient is at risk of heart failure. In such cases, a thiazide-like diuretic such as chlorthalidone or indapamide should be used instead of conventional thiazides like bendroflumethiazide and hydrochlorothiazide. If a CCB is not tolerated, a thiazide-like diuretic should be offered to treat hypertension. Indapamide is a thiazide-like diuretic that is associated with less hyponatraemia compared to bendroflumethiazide, making it an appropriate choice for first-line therapy in elderly patients. Even if the target BP is not reached on two or more agents, it is important to continue therapy.

Regardless of the circumstances, the loss of HGV licence is indicated by ICD.

DVLA Guidelines for Cardiovascular Disorders and Driving

The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

The echocardiogram indicates that there is some level of left ventricular dysfunction. To manage this condition, it is crucial to initiate treatment with an ACE inhibitor. This medication will not only regulate the patient’s blood pressure but also decelerate the decline in her heart’s performance. Additionally, a beta-blocker is recommended as there is evidence of heart failure.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Understanding ABPI and its Interpretation

The Ankle-Brachial Pressure Index (ABPI) is a ratio that compares the systolic pressure in the ankle to that in the arm. It is a non-invasive test that helps diagnose peripheral arterial disease (PAD), a condition that affects blood flow to the legs and feet.

An ABPI of less than 0.9 indicates the presence of PAD, while an ABPI of less than 0.8 suggests a higher risk of developing ulcers. An ABPI of less than 0.5 indicates critical ischaemia, a severe form of PAD that can lead to tissue damage and even amputation.

On the other hand, an ABPI of more than 1.5 is likely due to non-compressible vessels, which means that the arteries are too stiff to be accurately measured. In such cases, the ABPI cannot be relied upon to guide clinical decisions.

In summary, the ABPI is a useful tool in diagnosing and assessing the severity of PAD. Healthcare professionals should interpret the results carefully and take appropriate action based on the patient’s individual circumstances.

This man is experiencing heart failure due to ischaemic heart disease, which is a leading cause of death among men in the UK. Beta-blockers are the only medication proven to reduce all-cause mortality in patients with heart failure with reduced ejection fraction, and they can also help control hypertension. However, before starting treatment, his blood pressure and pulse should be checked to ensure that he is not at risk of bradycardia or hypotension. Spironolactone is not recommended for improving mortality in heart failure patients, but it can be used to treat hypertension and oedema. U&Es should be monitored regularly to avoid renal function deterioration and hyperkalaemia. Amlodipine and furosemide have not been shown to improve mortality in heart failure patients, but they can be used to control hypertension and oedema, respectively. U&Es should also be monitored regularly when using these medications. Ramipril has been shown to reduce hospital admissions in heart failure patients, but it can impair renal function and cause hyperkalaemia. U&Es should be checked regularly, and the medication should not be initiated if the patient’s potassium level is too high. Patients should also be advised to stop taking ramipril during diarrhoea or vomiting illnesses to avoid dehydration and acute kidney injury.

Investigations for Suspected Heart Failure: Importance of ECG and Natriuretic Peptides

When a patient is suspected of having heart failure, several investigations are recommended to confirm the diagnosis and determine the underlying cause. Routine blood tests, including full blood count, urea and electrolytes, liver function tests, thyroid function tests, and blood glucose, are typically performed. However, the results of these tests alone are not sufficient to diagnose heart failure.

An electrocardiogram (ECG) is also commonly performed, although its predictive value for heart failure is limited. A normal ECG can make left ventricular systolic dysfunction unlikely, with a negative predictive value of 98%. On the other hand, an abnormal ECG may indicate the need for further testing, such as echocardiography.

Serum natriuretic peptides, which are released by the heart in response to increased pressure or volume, can also be helpful in diagnosing heart failure. If these levels are normal, the diagnosis of heart failure is less likely. However, this test is not always available or necessary in the initial investigation.

A chest x-ray can provide supportive evidence for heart failure and rule out other potential causes of breathlessness. It is important to note that oxygen saturation may be normal in heart failure, so this alone cannot be used to rule out the condition.

Echocardiography is the gold standard for diagnosing heart failure and determining the underlying cause. It is recommended in patients who have either a raised natriuretic peptide level or an abnormal ECG. By providing detailed images of the heart’s structure and function, echocardiography can help guide treatment decisions and improve outcomes for patients with heart failure.

In summary, a combination of tests is necessary to diagnose heart failure and determine the best course of treatment. The ECG and natriuretic peptides can provide important clues, but echocardiography is essential for confirming the diagnosis and identifying the underlying cause.

Understanding Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina

Non-ST elevation myocardial infarction (NSTEMI) is a condition that is diagnosed in patients with chest pain who have elevated troponin T levels without the typical ECG changes of acute MI, such as Q-waves and ST elevation. Instead, there may be persistent or transient ST-segment depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, or no ECG changes at all. On the other hand, unstable angina is diagnosed when there is chest pain but no rise in troponin levels.

Despite their differences, both NSTEMI and unstable angina are grouped together as acute coronary syndromes. In the acute phase, 5-10% of patients may experience death or re-infarction. Additionally, another 5-10% of patients may experience death due to recurrent myocardial infarction in the month after an acute episode.

To manage these patients, many units take an aggressive approach with early angiography and angioplasty. By understanding the differences between NSTEMI and unstable angina, healthcare professionals can provide appropriate and timely treatment to improve patient outcomes.

Here are the recommended doses of adrenaline for Adult Life Support (ALS):
– Anaphylaxis: Administer 0.5mg or 0.5ml of 1:1,000 adrenaline via intramuscular injection.
– Cardiac arrest: Administer 1 mg of adrenaline.

Understanding Adrenaline and Its Effects on the Body

Adrenaline is a hormone that is responsible for the body’s fight or flight response. It is released by the adrenal glands and acts on both alpha and beta adrenergic receptors. Adrenaline has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle.

Adrenaline also has different actions on alpha and beta adrenergic receptors. It inhibits insulin secretion by the pancreas and stimulates glycogenolysis in the liver and muscle through alpha receptors. On the other hand, it stimulates glucagon secretion in the pancreas, ACTH, and lipolysis by adipose tissue through beta receptors. Adrenaline also acts on beta 2 receptors in skeletal muscle vessels, causing vasodilation.

Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest. The recommended adult life support adrenaline doses for anaphylaxis are 0.5ml 1:1,000 IM, while for cardiac arrest, it is 10ml 1:10,000 IV or 1 ml of 1:1000 IV. However, accidental injection of adrenaline can occur, and in such cases, local infiltration of phentolamine is recommended.

In conclusion, adrenaline is a hormone that plays a crucial role in the body’s response to stress. It has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle. Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest, and accidental injection can be managed through local infiltration of phentolamine.

In 2014, the NICE guidelines were updated regarding the use of statins for primary and secondary prevention. Patients with established cardiovascular disease are now recommended to be treated with Atorvastatin 80 mg. If the LDL cholesterol levels remain high, it is suitable to consider switching the patient’s medication.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

As a primary prevention measure for cardiovascular disease, it is recommended to discuss and suggest statin therapy to the patient. The target for clinic blood pressure should be less than 140/90 mmHg and less than 135/85 mmHg for ambulatory blood pressure monitoring. To achieve this, amlodipine and lifestyle advice should be offered along with atorvastatin.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Mitral Stenosis: Symptoms and Findings

Mitral stenosis is a condition where patients experience dyspnoea and pulmonary oedema due to increased left atrial pressure. This is more common in younger patients and can be exacerbated by situations of increased blood volume, such as during pregnancy. As a result, a previously asymptomatic patient may present to their GP during pregnancy.

Typical findings in mitral stenosis include a small pulse that may be irregularly irregular. Jugular venous pressure is only raised if there is heart failure, right ventricular hypertrophy, tapping apex beat, loud S1, loud P2 if pulmonary hypertension, opening snap, mid-diastolic murmur heard at the apex only, or presystolic accentuation murmur if no atrial fibrillation.

In summary, patients with mitral stenosis may experience dyspnoea and pulmonary oedema, and typical findings include a small pulse and irregularly irregular heartbeat. Jugular venous pressure may only be raised in certain situations.

Predisposing Factors for Pulmonary Embolism

Pulmonary embolism is a serious medical condition that occurs when a blood clot travels to the lungs and blocks blood flow. Certain factors can increase the risk of developing pulmonary embolism.

Strong predisposing factors, with an odds ratio greater than 10, include fractures (hip or leg), hip or knee replacement, major general surgery, major trauma, and spinal cord injury.

Moderate predisposing factors, with an odds ratio between 2 and 9, include arthroscopic knee surgery, central venous lines, chemotherapy, chronic heart or respiratory failure, hormone replacement therapy, malignancy, oral contraceptive therapy, paralytic stroke, pregnancy/postpartum, previous venous thromboembolism, and thrombophilia.

Weak predisposing factors, with an odds ratio of 2 or less, include bed rest for more than 3 days, immobility due to sitting (such as prolonged car or air travel), increasing age, laparoscopic surgery (such as cholecystectomy), obesity, pregnancy/antepartum, and varicose veins.

It is important to be aware of these predisposing factors and take appropriate measures to prevent pulmonary embolism, especially in high-risk individuals.

Managing Atrial Fibrillation Post-Stroke

Atrial fibrillation is a major risk factor for ischaemic stroke, making it crucial to identify and treat the condition in patients who have suffered a stroke or transient ischaemic attack (TIA). However, before starting any anticoagulation or antiplatelet therapy, it is important to rule out haemorrhage. For long-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor. The timing of when to start treatment depends on whether it is a TIA or stroke. In the case of a TIA, anticoagulation for AF should begin immediately after imaging has excluded haemorrhage. For acute stroke patients, anticoagulation therapy should be initiated after two weeks in the absence of haemorrhage. Antiplatelet therapy should be given during the intervening period. However, if imaging shows a very large cerebral infarction, the initiation of anticoagulation should be delayed.

Patients with a serious mental health disorder and those taking antipsychotics may have their cardiovascular disease risk underestimated by QRISK2.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

Managing Peripheral Arterial Disease

Peripheral arterial disease (PAD) is closely associated with smoking, and patients who still smoke should be provided with assistance to quit. Comorbidities such as hypertension, diabetes mellitus, and obesity should also be treated. All patients with established cardiovascular disease, including PAD, should be taking a statin, with atorvastatin 80 mg currently recommended. In 2010, NICE recommended clopidogrel as the first-line treatment for PAD patients over aspirin.

Exercise training has been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions. Severe PAD or critical limb ischaemia may be treated with endovascular or surgical revascularization, with endovascular techniques typically used for short segment stenosis, aortic iliac disease, and high-risk patients. Surgical techniques are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.

Drugs licensed for use in PAD include naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life, and cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, which is not recommended by NICE.

Monitoring Requirements for Statin Treatment

It is important to monitor patients who are undergoing statin treatment. Even if their liver function tests are normal at the beginning, they should be repeated after three months. At this point, a lipid profile should also be checked to see if the treatment targets have been achieved in terms of non-HDL cholesterol reduction. After 12 months, liver function should be checked again. If it remains normal throughout, there is no need for routine rechecking unless clinically indicated or if the statin dosage is increased. In such cases, liver function should be checked again after three months and after 12 months of the dose change.

If Cynthia’s blood pressure is equal to or greater than 180/120 mmHg and she has no worrying signs, the first step is to urgently investigate for any damage to her organs.

According to NICE guidelines, if a person has severe hypertension but no symptoms or signs requiring immediate referral, investigations for target organ damage should be carried out as soon as possible. Since Cynthia has no such symptoms or signs, investigating for target organ damage is the correct option.

If target organ damage is found, antihypertensive drug treatment should be considered immediately, without waiting for the results of ABPM or HBPM. Therefore, prescribing a calcium channel blocker is not the correct answer as assessing for organ damage is the more urgent priority.

Repeating clinic blood pressure measurement within 7 days at this stage would not be helpful in guiding further management, as assessing for target organ damage is the priority. NICE recommends repeating clinic blood pressure measurement within 7 days only if no target organ damage is identified.

Assessing for target organ damage involves testing for protein and haematuria in the urine, measuring HbA1C, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol, and HDL cholesterol in the blood, examining the fundi for hypertensive retinopathy, and performing a 12-lead electrocardiograph.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

Managing Atrial Fibrillation: Choosing the Right Medication

Patients with atrial fibrillation (AF) are at risk of stroke and require proper management. The initial approach to managing AF involves either rhythm or rate control, depending on the patient’s age, comorbidity, and the duration of AF.

According to the National Institute for Health and Care Excellence guidelines, rate-limiting calcium antagonists or β-blockers are recommended as first-line treatment for many patients requiring rate-control medication. However, β-blockers are contraindicated in patients with asthma.

Rate-limiting calcium channel blockers such as verapamil and diltiazem are alternative options. Digoxin is only recommended for very sedentary patients as a first-line medication, as it doesn’t control heart rate during exertion. However, it can be used in combination with a first-line drug if rate control is poor. The target for rate control should be a resting heart rate of less than 110 bpm, and lower if the patient remains symptomatic.

Choosing the right medication for managing AF is crucial in reducing the risk of stroke and improving the patient’s quality of life.

It is safe to use compression therapy for patients with leg ulcers who have an ABPI of 0.8 or higher.

Ankle-Brachial Pressure Index for Evaluating Peripheral Arterial Disease

The ankle-brachial pressure index (ABPI) is a diagnostic tool used to evaluate peripheral arterial disease (PAD). It measures the ratio of systolic blood pressure in the lower leg to that in the arms. A lower blood pressure in the legs, resulting in an ABPI of less than 1, is an indicator of PAD. This test is particularly useful in evaluating patients with suspected PAD, such as a male smoker who presents with intermittent claudication.

In addition, it is important to determine the ABPI in patients with leg ulcers. Compression bandaging is often used to treat venous ulcers, but it can be harmful in patients with PAD as it further restricts blood supply to the foot. Therefore, ABPIs should always be measured in patients with leg ulcers to determine if compression bandaging is appropriate.

The interpretation of ABPI values is as follows: a value greater than 1.2 may indicate calcified, stiff arteries, which can be seen in advanced age or PAD. A value between 1.0 and 1.2 is considered normal, while a value between 0.9 and 1.0 is acceptable. A value less than 0.9 is likely indicative of PAD, and values less than 0.5 indicate severe disease that requires urgent referral. The ABPI is a reliable test, with values less than 0.90 having a sensitivity of 90% and a specificity of 98% for PAD. Compression bandaging is generally considered acceptable if the ABPI is greater than or equal to 0.8.

Understanding Hypertension Diagnosis and Management

Hypertension is a common condition that requires careful diagnosis and management. According to the 2019 NICE guidance on Hypertension (NG136), ambulatory or home blood pressure should be checked if a patient has a blood pressure equal to or greater than 140/90 mmHg. If the systolic reading is above 140 mmHg, it is considered a sign of hypertension.

The guidelines also state that lifestyle advice should be given to all patients, and drug treatment should be considered if there are signs of end organ damage or if the patient’s CVD risk is greater than 10% in 10 years. For patients under 40 years old, referral to a specialist should be considered.

It is important to note that NICE guidance is not the only source of information on hypertension diagnosis and management. While it is important to have an awareness of the latest guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.

In summary, understanding the diagnosis and management of hypertension is crucial for general practitioners. The 2019 NICE guidance on Hypertension provides important information on thresholds for diagnosis and management, but it is important to consider other sources of information as well.

For a patient with hypertension who is under 55 years old and cannot tolerate calcium channel blockers, the next line of therapy is a thiazide-like diuretic such as indapamide. It is important to note that drug intolerance refers to the inability to tolerate adverse effects of a medication, while tolerance refers to the ability to tolerate adverse effects and continue taking the medication. Beta-blockers like atenolol may be considered as a fourth-line intervention depending on the patient’s potassium levels, but they are no longer part of initial hypertension management. Candesartan should not be co-prescribed with an ACE inhibitor like ramipril unless directed by a specialist. Diltiazem, a calcium channel blocker, is also not recommended as the patient has been found to be intolerant to this class of medication.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

If a person aged 40 or over has appetite loss and is a smoker, an urgent chest X-ray should be offered within two weeks, according to the updated 2015 NICE guidelines. This is because appetite loss is now considered a potential symptom of lung cancer. While counseling, smoking cessation, and a career change may be helpful, investigating the possibility of lung cancer is the most urgent action required. It is important to address each issue separately, as trying to tackle all three at once could be overwhelming for the patient.

Referral Guidelines for Lung Cancer

Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.

For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.

In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.

Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.

Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

Guidelines for Measuring Blood Pressure

When measuring blood pressure, it is important to follow certain guidelines to ensure accurate readings. The patient should be seated for at least five minutes, in a relaxed state without moving or speaking. Blood pressure should be recorded three times, initially testing in both arms. If there is a sustained difference of more than 20 mmHg, use the arm with the higher reading for subsequent measurements. The arm must be supported at the level of the heart.

If the blood pressure is 140/90 mmHg or higher, up to three readings should be taken, and the lower of the last two recorded as the blood pressure. It is important to note that automated devices may not measure blood pressure accurately if there is pulse irregularity, such as atrial fibrillation. In such cases, blood pressure should be measured manually using direct auscultation over the brachial artery. By following these guidelines, healthcare professionals can ensure accurate blood pressure readings for their patients.

Antihypertensive Therapy Guidelines

Guidelines for Antihypertensive therapy recommend different treatments based on age and ethnicity. For individuals under 55 years old, an angiotensin-converting enzyme (ACE) inhibitor is the first line of treatment. If an ACE inhibitor is not tolerated, a low-cost angiotensin receptor blocker (ARB) can be offered. However, ACE inhibitors and ARBs should not be combined to treat hypertension.

For individuals over 55 years old, or of African or Caribbean origin of any age, a calcium-channel blocker (CCB) is recommended. If a CCB is not suitable, a thiazide-like diuretic can be offered. It is important to note that ACE inhibitors and ARBs should not be routinely prescribed to pregnant women.

Overall, it is important to establish whether or not a patient is diabetic before determining the appropriate Antihypertensive therapy. Following these guidelines can help effectively manage hypertension and reduce the risk of associated complications.

The recommended target INR for mechanical valves is 3.0 for aortic valves and 3.5 for mitral valves.

Prosthetic Heart Valves: Options and Considerations

Prosthetic heart valves are commonly used to replace damaged or diseased valves in the heart. The two main options for replacement are biological (bioprosthetic) or mechanical valves. Bioprosthetic valves are usually derived from bovine or porcine sources and are preferred for older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve location. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease.

It is important to consider the patient’s age, medical history, and lifestyle when choosing a prosthetic heart valve. While bioprosthetic valves may not require long-term anticoagulation, they may need to be replaced sooner than mechanical valves. Mechanical valves, on the other hand, may require lifelong anticoagulation, which can be challenging for some patients. Additionally, following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis. Therefore, it is crucial to weigh the benefits and risks of each option and make an informed decision with the patient.

To improve the management of hypertension that is not well-controlled despite the use of an ACE inhibitor and a calcium channel blocker, it is recommended to include a thiazide-like diuretic.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Drug Interactions with Fruit Juices and Supplements

Grapefruit juice can significantly increase the serum concentrations of certain statins by reducing their first-pass metabolism in the small intestine through the inhibition of CYP3A4. Therefore, it is recommended to avoid consuming large amounts of grapefruit juice while taking atorvastatin or to adjust the dosage accordingly. CYP3A4 is a member of the cytochrome P450 system.

On the other hand, while an interaction between cranberry juice and warfarin has been recognized, there have been no reported interactions with other drugs metabolized via the P450 system. Additionally, there have been no known interactions between statins, carrot juice, garlic, or omega-3 fish oils. However, it is important to note that according to NICE CG172, patients should no longer be advised to take omega-3 supplements to prevent another MI.

It is not recommended to prescribe ACE inhibitors to patients with moderate-severe aortic stenosis, making ramipril an inappropriate choice. Similarly, angiotensin-II receptor blockers like losartan are also contraindicated. Furosemide is not indicated for hypertension treatment. According to NICE CKS guidance, a combination of thiazide-like diuretics and calcium channel blockers is recommended, making indapamide a suitable alternative to ramipril and losartan. Digoxin has no role in hypertension treatment in this case.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Understanding the Importance of NICE Guidance on Hypertension

This passage discusses the latest NICE guidance on hypertension and its importance in evaluating the long-term balance of treatment benefit and risks for adults under 40 with hypertension. However, it also highlights the criticism that the guidance has received from some clinicians, particularly regarding the use of ambulatory and home blood pressure monitoring. It is important to have a balanced view and be aware of other guidelines and consensus opinions in medicine. While AKT questions may not contradict NICE guidance, it is essential to consider the bigger picture and not solely rely on the latest guidance. Remember that the questions test your knowledge of national guidance and consensus opinion. Proper understanding of NICE guidance on hypertension is crucial, but it is equally important to have a broader perspective on the matter.

Liver Function and Statin Therapy

Liver function should be assessed before starting statin therapy. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can be used. It is important to repeat liver function tests within the first three months of treatment and then at 12 months, as well as if a dose increase is made or if clinically indicated.

In the case of a modest ALT elevation due to fatty deposition in the liver, statin therapy can still be beneficial for primary prevention, especially if the patient’s Qrisk2 score is over 10%. Mild derangement in liver function is not uncommon in overweight type 2 diabetics. The patient can be treated with the usual NICE-guided primary prevention dose of atorvastatin, which is 20 mg nocte. A higher dose or alternative statin may be required in the future, depending on the patient’s response to the initial treatment and lifestyle modifications. The slight ALT rise doesn’t necessarily require a lower statin dose.

Common Congenital Heart Defects in Newborns

Congenital heart defects are abnormalities in the structure of the heart that are present at birth. Here are some common congenital heart defects in newborns:

Coarctation of the aorta: This defect is a narrowing of the aorta, usually just distal to the origin of the left subclavian artery, close to the ductus arteriosus. It usually presents between day 2 and day 6 with symptoms of heart failure as the ductus arteriosus closes. The patient may have weak femoral pulses and a systolic murmur in the left infraclavicular area.

Fallot’s tetralogy: This defect consists of a large ventricular septal defect, overriding aorta, right ventricular outflow obstruction, and right ventricular hypertrophy. It leads to a right to left shunt and low oxygen saturation, which can cause cyanosis. Most cases are diagnosed antenatally or on investigation of a heart murmur.

Ductus arteriosus: The ductus arteriosus connects the pulmonary artery to the proximal descending aorta. It is a normal structure in fetal life but should close after birth. Failure of the ductus arteriosus to close can lead to overloading of the lungs because a left to right shunt occurs. Heart failure may be a consequence. A continuous (“machinery”) murmur is best heard at the left infraclavicular area or upper left sternal border.

Transient tachypnoea of the newborn: This condition is seen shortly after delivery and consists of a period of rapid breathing. It is likely due to retained lung fluid and usually resolves over 24-48 hours. However, it is important to observe for signs of clinical deterioration.

Ventricular septal defects: These defects vary in size and haemodynamic consequences. The presence of a defect may not be obvious at birth. Classically there is a harsh systolic murmur that is best heard at the left sternal edge. With large defects, pulmonary hypertension may develop resulting in a right to left shunt (Eisenmenger’s syndrome). Patients with the latter may have no murmur.

In conclusion, early detection and management of congenital heart defects in newborns are crucial for better outcomes.

Rate Control vs Rhythm Control in Atrial Fibrillation: Recent Trials and Treatment Guidelines

Recent trials have confirmed that for most patients with atrial fibrillation, rate control is superior to rhythm control in terms of survival benefit. However, DC cardioversion may be considered for new onset and younger patients. The National Institute for Health and Care Excellence (NICE) guidelines recommend first-line therapy with ß-blockers or rate-limiting calcium antagonists, or digoxin if these are not tolerated. Verapamil should not be used in combination with a ß-blocker. These guidelines provide a framework for the management of atrial fibrillation and can help clinicians make informed treatment decisions.

If you have hypertension and belong to Group 1, there is no requirement to inform the DVLA. However, if you belong to Group 2, your blood pressure must consistently remain below 180/100 mmHg.

DVLA Guidelines for Cardiovascular Disorders and Driving

The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

Treatment options for Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD) is a condition that causes intermittent claudication. Antiplatelet therapy is recommended for those with symptomatic disease to reduce major cardiovascular events. Clopidogrel is suggested as the drug of first choice by the National Institute for Health and Care Excellence (NICE). Angiotensin converting enzyme inhibitors have been shown to reduce cardiovascular morbidity and mortality in patients with PAD. However, they should be carefully monitored as more than 25% of patients have co-existent renal artery stenosis. Statins are also recommended as they reduce the risk of mortality, cardiovascular events and stroke in patients with PAD. Naftidrofuryl oxalate is an option for the treatment of intermittent claudication in people with PAD for whom vasodilator therapy is considered appropriate. Amlodipine, a calcium channel blocker, is not indicated for this case.

Impedance of Ventricular Contraction in Constrictive Pericarditis and Cardiac Tamponade

Both constrictive pericarditis and cardiac tamponade can cause impedance of ventricular contraction, which becomes more severe as the diaphragm descends. This results in an increase in venous pressure during inspiration, known as Kussmaul’s sign.

To assess the jugular venous pressure (JVP), the patient should be lying at a 45-degree angle. Normally, the JVP is not palpable except in severe tricuspid regurgitation, and the pressure is assessed relative to the manubrium sterni. In early left ventricular failure, the JVP may be normal, but as fluid retention increases, the veins become congested, leading to congestive cardiac failure (CCF).

In summary, both constrictive pericarditis and cardiac tamponade can lead to impedance of ventricular contraction and an increase in venous pressure during inspiration, which can be assessed through the JVP. Congestion of the veins can also occur in CCF.

Recommended Drug Treatment for Secondary Prevention of Myocardial Infarction

The recommended drug treatment for secondary prevention of myocardial infarction (MI) includes a combination of medications. These medications include a β-blocker, an angiotensin-converting enzyme (ACE) inhibitor, a statin, and dual antiplatelet treatment. Previously, statin treatment was only offered to patients with a cholesterol level of > 5 mmol/l. However, it has been shown that all patients with coronary heart disease benefit from a reduction in total cholesterol and LDL.

β-blockers are estimated to prevent deaths by 12/1000 treated/year, while ACE inhibitors reduce deaths by 5/1000 treated in the first month post-MI. Trials have also shown reduced long-term mortality for all patients. Aspirin should be given indefinitely, and clopidogrel should be given for up to 12 months.

In summary, the recommended drug treatment for secondary prevention of myocardial infarction includes a combination of medications that have been shown to reduce mortality rates. It is important for patients to continue taking these medications as prescribed by their healthcare provider.

If the clinic reading is equal to or greater than 140/90 mmHg, it is recommended to offer ABPM/HBPM. However, if the lower reading in the consultation is below 140/90 mmHg, no immediate action is necessary according to NICE guidelines.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

High Risk Patients for Cardiovascular Disease

Certain patients are automatically considered at high risk for cardiovascular disease (CVD) and do not require the use of a CVD risk assessment tool such as QRISK2. These high-risk patients include those with pre-existing CVD, those aged 85 and above, those with an eGFR <60 ml/min/1.73m2 and/or albuminuria, those with familial hypercholesterolaemia or other inherited lipid disorders, and those with type 1 diabetes who are over 40 years old, have a history of diabetes for at least 10 years, have established nephropathy, or have other CVD risk factors. However, for patients with a BMI of 38, a CVD risk assessment tool should be used. It is important to note that for patients with a BMI higher than 40 kg/m2, their risk may be underestimated by standard CVD risk assessment tools. By identifying high-risk patients, healthcare providers can take appropriate measures to prevent and manage CVD.

As part of the comprehensive lifestyle approach to managing heart failure, it is recommended to offer an annual influenza vaccine. While pneumococcal vaccination should also be provided to patients with heart failure, it doesn’t need to be administered every year. The patient in question is already taking the maximum doses of ramipril and bisoprolol approved for heart failure treatment, and their blood pressure is well-managed with their current medications. Currently, there are no indications that increasing the dose of furosemide would benefit the patient’s heart failure management, and it may even cause harm such as electrolyte imbalances.

Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

ACE Inhibitors and Angioedema

ACE inhibitors are medications that can lead to the development of angioedema, a condition characterized by swelling in various parts of the body. This is because ACE inhibitors block the action of the ACE enzyme, which is responsible for breaking down bradykinin. When bradykinin accumulates in the body, it causes blood vessels to dilate and become more permeable, leading to the accumulation of fluid in the interstitium. This can result in rapid swelling, particularly in areas with less connective tissue, such as the face.

Interestingly, ACE inhibitor-induced angioedema appears to be more common in African-American individuals. If angioedema occurs, the medication should be discontinued immediately and an alternative treatment should be sought. One option is an angiotensin II receptor antagonist, which works similarly to ACE inhibitors but doesn’t affect bradykinin levels. It is important to monitor patients closely for signs of angioedema when prescribing ACE inhibitors, particularly in those with a history of the condition.

ACE inhibitors pose a significant risk of profound hypotension in patients with aortic stenosis. However, the co-prescription of bendroflumethiazide, a weak diuretic, is commonly used and doesn’t increase the risk of hypotension as seen with high-dose loop diuretics such as furosemide 80 mg bd. Patients with chronic kidney disease stage 2, which is characterized by a glomerular filtration rate of > 60 mL/min/1.73 m², are unlikely to experience significant side effects.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

The patient exhibits symptoms of congestive heart failure, which can be managed with loop diuretics and nitrates in acute or decompensated cases. However, these medications do not improve long-term survival. To reduce mortality in patients with left ventricular failure, ACE-inhibitors, beta-blockers, angiotensin receptor blockers, aldosterone antagonists, and hydralazine with nitrates have all been proven effective. Digoxin can reduce hospital admissions but not mortality, and is typically used in patients with worsening heart failure despite initial treatments or those with co-existing atrial fibrillation.

Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

St John’s Wort and Medication Interactions

St John’s wort is a popular natural remedy for depressive symptoms. However, it is important to note that it is a liver enzyme inducer, which can lead to interactions with other medications. For example, St John’s wort may reduce the efficacy of warfarin, a blood thinner, requiring an increased dose to maintain the desired level of anticoagulation. It may also reduce the efficacy of digoxin, a medication used to treat heart failure. Therefore, it is important to discuss the use of St John’s wort with a healthcare provider before taking it in combination with other medications. By doing so, potential interactions can be identified and managed appropriately.

Even after undergoing catheter ablation for atrial fibrillation, patients must continue taking anticoagulants for an extended period based on their CHA2DS2-VASc score.

Atrial fibrillation (AF) is a heart condition that requires prompt management. The management of AF depends on the patient’s haemodynamic stability and the duration of the AF. For haemodynamically unstable patients, electrical cardioversion is recommended. For haemodynamically stable patients, rate control is the first-line treatment strategy, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin are commonly used to control the heart rate. Rhythm control is another treatment option that involves the use of medications such as beta-blockers, dronedarone, and amiodarone. Catheter ablation is recommended for patients who have not responded to or wish to avoid antiarrhythmic medication. The procedure involves the use of radiofrequency or cryotherapy to ablate the faulty electrical pathways that cause AF. Anticoagulation is necessary before and during the procedure to reduce the risk of stroke. The success rate of catheter ablation varies, with around 50% of patients experiencing an early recurrence of AF within three months. However, after three years, around 55% of patients who have undergone a single procedure remain in sinus rhythm.

Hypertrophic obstructive cardiomyopathy (HCM) is a condition where the left ventricle of the heart becomes enlarged, often affecting the interventricular septum and causing a blockage in the left ventricular outflow tract. Patients with HCM typically experience shortness of breath, but may also have angina or fainting spells. Physical examination may reveal a prominent presystolic S4 gallop, a harsh systolic ejection murmur, and a left ventricular apical impulse. The Valsalva manoeuvre and standing up from a squatting position can increase the intensity of the murmur. An echocardiogram is the preferred diagnostic test for HCM. Syncope occurs in 15-25% of HCM patients, and recurrent syncope in young patients may indicate an increased risk of sudden death. Aortic stenosis, on the other hand, typically affects older patients and causes exertional syncope. The ejection systolic murmur associated with aortic stenosis is loudest at the upper right sternal border and radiates to the carotids. It increases with squatting and decreases with standing and isometric muscular contraction. Atrial fibrillation can also cause syncope, but if it is associated with HCM, the underlying cause is still HCM. Vasovagal syncope is usually triggered by prolonged standing or exposure to hot, crowded environments. The term syncope excludes other conditions that cause altered consciousness, such as seizures or shock.

Treatment Options for Symptomatic Heart Failure

Symptomatic heart failure can be managed with various medications. Loop diuretics such as furosemide can provide relief from symptoms of fluid overload. However, it doesn’t alter the prognosis. Aldosterone antagonists may be considered for patients who remain symptomatic despite a combination of loop diuretics, ACE inhibitors, and beta-blockers. ACE inhibitors should be given to all patients with a left ventricular ejection fraction of 40% or less, regardless of symptom severity, as it has been shown to improve ventricular function, reduce mortality, and hospital admission. Beta-blockers should also be used in patients with symptomatic heart failure and a left ventricular ejection fraction ≤ 40%, as long as they are tolerated and not contraindicated. Digoxin is used for rate control but is not recommended for rapid symptom relief.

According to NICE guidelines, if a patient needs a third anti-anginal medication, they should be referred for evaluation of a more permanent solution such as PCI or CABG. Although ACE inhibitors may be beneficial for certain patients with stable angina, they would not alleviate his angina symptoms.

Angina pectoris can be managed through lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.

Patients with heart failure should exercise caution when using NSAIDs as they may lead to fluid retention, making oral NSAIDs like ibuprofen unsuitable.

Medications to Avoid in Patients with Heart Failure

Patients with heart failure need to be cautious when taking certain medications as they may exacerbate their condition. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil should also be avoided due to its negative inotropic effect. NSAIDs and glucocorticoids should be used with caution as they can also cause fluid retention. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin outweigh the risks. Class I antiarrhythmics, such as flecainide, should also be avoided as they have a negative inotropic and proarrhythmic effect. It is important for healthcare providers to be aware of these medications and their potential effects on patients with heart failure.

Digoxin Toxicity and its Management

Digoxin toxicity is a condition that can cause a number of symptoms, including yellow vision and nausea. It can also lead to various arrhythmias, such as heart block, supraventricular and ventricular tachycardia. This toxicity can be associated with certain medications, including erythromycin, tetracyclines, quinidine, calcium channel blockers, captopril, and amiodarone.

In addition to medication interactions, it is important to monitor renal function as deteriorating creatinine clearance can also contribute to toxicity. Management of digoxin toxicity involves measuring digoxin levels, avoiding or reducing the dose, and in severe cases, admission for cardiac monitoring and consideration of digoxin antibody therapy.

To summarize, digoxin toxicity is a serious condition that requires careful monitoring and management to prevent complications. By being aware of the medications that can interact with digoxin and monitoring renal function, healthcare providers can help prevent and manage this condition effectively.

Treatment for Heart Failure with Left Ventricular Systolic Dysfunction

Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are recommended for patients with heart failure due to left ventricular systolic dysfunction, regardless of their NYHA functional class. The 2003 NICE guidance suggests starting with ACE inhibitors and then adding beta-blockers, but the 2010 update recommends using clinical judgement to determine which drug to start first. For example, a beta-blocker may be more appropriate for a patient with angina or tachycardia. However, combination treatment with an ACE inhibitor and beta-blocker is the preferred first-line treatment for patients with heart failure due to left ventricular dysfunction. It is important to start drug treatment in a stepwise manner and to ensure the patient’s condition is stable before initiating therapy.

Clopidogrel is the top choice for antiplatelet therapy in the secondary prevention of stroke. As a second option, aspirin can be combined with modified-release dipyridamole. However, there is some discrepancy among guidelines regarding the preferred antiplatelet for transient ischaemic attack. While NICE recommends aspirin and dipyridamole due to clopidogrel lack of licensing for this indication, the Royal College of Physicians advocates for clopidogrel. It is worth noting that clopidogrel is associated with frequent gastrointestinal side effects.

The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The guidelines provide recommendations for the management of acute stroke, including maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke. If the cholesterol is > 3.5 mmol/l, patients should be commenced on a statin.

Thrombolysis with alteplase should only be given if it is administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. There are absolute and relative contraindications to thrombolysis, including previous intracranial haemorrhage, intracranial neoplasm, and active bleeding. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends considering thrombectomy together with intravenous thrombolysis for people last known to be well up to 24 hours previously.

Secondary prevention recommendations from NICE include the use of clopidogrel and dipyridamole. Clopidogrel is recommended ahead of combination use of aspirin plus modified-release dipyridamole in people who have had an ischaemic stroke. Aspirin plus MR dipyridamole is recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated. MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

Statin-Associated Myopathy and Drug Interactions

Statin-associated myopathy is a potential side effect that affects up to 5% of individuals taking statins. This condition can be exacerbated by the co-prescription of certain drugs, including calcium channel blockers, macrolide antibiotics, fibrates, amiodarone, and grapefruit juice. Even patients who tolerate statins well may experience myopathy or rhabdomyolysis when these agents are added to their treatment regimen.

It is important for healthcare providers to be aware of these potential drug interactions and to monitor patients closely for signs of myopathy. Additionally, NICE guidance on Myocardial infarction: secondary prevention (NG185) advises against the use of omega-3 capsules to prevent another MI. By staying informed and following evidence-based guidelines, healthcare providers can help ensure the safety and well-being of their patients.

Understanding NICE Guidelines on Hypertension for the AKT Exam

The NICE guidelines on Hypertension (NG136) published in September 2019 provide important information for general practitioners on the management of hypertension. However, it is important to remember that these guidelines have attracted criticism from some clinicians for being over complicated and insufficiently evidence-based. While it is essential to have an awareness of NICE guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.

One example of a question that may be asked in the AKT exam relates to the cut-offs for high blood pressure on ambulatory monitoring. According to the NICE guidelines, stage 1 hypertension is defined as a blood pressure of 135-149/85-94 mmHg and should be treated if there is end organ damage, diabetes, or a 10-year CVD risk of 10% or more. Stage 2 hypertension is defined as blood pressure equal to or greater than 150/95 mmHg and should be treated.

In the exam, you may be asked to determine the appropriate treatment for a patient with stage 1 hypertension. The NICE guidance suggests a calcium channel blocker in patients above 55 or Afro-Caribbean. However, it is important to note that lifestyle factors are also crucial in risk reduction.

While it is unlikely that you will be asked to select answers that contradict NICE guidance, it is essential to remember that the AKT exam tests your knowledge of national guidance and consensus opinion, not just the latest NICE guidance. Therefore, it is important to have a broader understanding of the subject matter and consider other guidelines and opinions.

NICE guidelines from 2011 acknowledge the issue of overtreatment of ‘white coat’ hypertension and recommend the use of ambulatory blood pressure monitoring (ABPM) to address this problem. ABPM is also considered a more reliable predictor of cardiovascular risk compared to clinic blood pressure readings, based on strong evidence.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

Managing Warfarin Patients on Antibiotics

When a patient on warfarin requires antibiotics, it is a common clinical scenario that requires careful management. While there is no need to stop warfarin or switch to aspirin, it is important to monitor the patient’s INR levels closely. Typically, extra INR monitoring should be performed three to five days after starting the antibiotics to check for any potential impact on the INR. If necessary, a dosing change for warfarin may be needed.

According to the British Committee for Standards in Haematology Guidelines for oral anticoagulation with warfarin (2011), it is important to follow specific recommendations for INR testing when a potential drug interaction occurs. By carefully monitoring INR levels and adjusting warfarin dosing as needed, healthcare providers can help ensure the safety and efficacy of treatment for patients on warfarin who require antibiotics.

Management of Mild Hypophosphataemia

In cases of mild hypophosphataemia, monitoring is often sufficient. It may be helpful to check vitamin D levels as it can affect phosphate uptake and renal excretion, along with parathyroid hormone (PTH). If there is a concurrent low magnesium level, it may indicate dietary deficiencies.

An ultrasound of the neck is not necessary unless there are signs of enlarged parathyroid glands. Oral phosphate is typically reserved for preventing refeeding syndrome in cases of anorexia, starvation, or alcoholism. Mild hypophosphataemia usually resolves on its own.

Parenteral phosphate may be considered in acute situations but requires inpatient monitoring of calcium, phosphate, and other electrolytes. Referral should only be considered if the patient is symptomatic, has short stature or skeletal deformities consistent with rickets, or if the hypophosphataemia is chronic or severe.

The threshold for stage 1 hypertension, as measured by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), is a reading of 135/85 mmHg.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Monitoring Statin Treatment for Primary Prevention

Following the initiation of statin treatment for primary prevention, it is recommended to have a repeat blood test after 3 months. The non-HDL cholesterol level should be interpreted to guide the next steps in management. The goal of treatment is to reduce non-HDL levels by 40% of the patient’s baseline. If adherence, timing of the dose, and lifestyle measures are in place, an increase in dose may be necessary.

It is not routine to investigate creatine kinase in this context, but it would be helpful to investigate unexplained muscle symptoms. Liver function tests are not an option, but NICE advises testing these 3 months and 12 months following statin initiation. If stable, no further monitoring for LFTs is required after this.

Monitoring Recommendations for Loop Diuretics

To ensure the safe and effective use of loop diuretics, the National Institute for Health and Care Excellence (NICE) recommends monitoring renal function, serum electrolytes, and blood pressure within 1-2 weeks after each dose increase. It is also important to check these parameters before starting treatment and after treatment initiation.

For patients with known chronic kidney disease (CKD), those aged 60 years or older, or those taking an ACE-I, ARB, or aldosterone antagonist, earlier monitoring (5-7 days) may be necessary. By closely monitoring these parameters, healthcare professionals can identify any potential adverse effects and adjust treatment accordingly to optimize patient outcomes.

Travel Restrictions After Myocardial Infarction

After experiencing a myocardial infarction (MI), also known as a heart attack, patients may wonder when it is safe to travel by air. The minimum time for flying after an uncomplicated MI is generally accepted to be seven days, although some authorities suggest waiting up to three weeks. It is important to note that this question specifically asks for the minimum time after an uncomplicated MI that would be safe for air travel.

Consensus national guidance in the UK, including advice from the Civil Aviation Authority and British Airways, supports the seven-day minimum for uncomplicated MI. Patients who have had a complicated MI should wait four to six weeks before flying. Patients with severe angina may require oxygen during the flight and should pre-book a supply with the airline. Patients who have undergone coronary artery bypass graft (CABG) or suffered a stroke should not travel for ten days. Decompensated heart failure or uncontrolled hypertension are contraindications to flying.

In summary, patients who have experienced an uncomplicated MI may fly after seven days without requiring an exercise test. It is important to follow national guidance and consult with a healthcare provider before making any travel plans after a heart attack.

Lipid Management in Primary Care

Lipid management is a common scenario in primary care, and NICE has produced guidance on Lipid modification (CG181) in the primary and secondary prevention of cardiovascular disease. The use of statins in primary prevention is supported by clinical trial data, with WOSCOPS (The West of Scotland Coronary Prevention Study) being a landmark trial. This study looked at statin versus placebo in men aged 45-65 with no coronary disease and a cholesterol >4 mmol/L, showing a reduction in all-cause mortality by 22% in the statin arm for a 20% total cholesterol reduction.

Other study data also supports the use of statins as primary prevention of coronary artery disease. The NICE Clinical Knowledge Summary on lipid modification – CVD prevention recommends Atorvastatin at 20 mg for primary prevention and 80 mg for secondary prevention. Risk is assessed using the QRISK2 calculator. Overall, lipid management is an important aspect of primary care, and healthcare professionals should be familiar with the latest guidance and clinical trial data to provide optimal care for their patients.

Sertraline for Depression in Patients with Recent MI or Unstable Angina

Sertraline is a medication that is both effective and well-tolerated for treating depression in patients who have recently experienced a myocardial infarction (MI) or unstable angina. In addition to its antidepressant properties, sertraline has been found to inhibit platelet aggregation. This makes it a valuable treatment option for patients who are at risk for blood clots and other cardiovascular complications. With its dual benefits, sertraline can help improve both the mental and physical health of patients who have experienced a cardiac event.

To maintain good control of hypertension in patients under 80 years of age, the target clinic blood pressure should be below 140/90 mmHg. In this case, the patient’s blood pressure is within the target range, indicating that their current medication regimen is effective and should not be altered. However, if their blood pressure was above 140/90 mmHg, increasing the ramipril dosage to 5mg could be considered before adding a third medication, as the amlodipine is already at its maximum dose.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

The Importance of Specialist Lipid Clinics in Managing Adverse Lipid Profiles

Specialist lipid clinics are crucial in managing adverse lipid profiles, particularly those with a familial origin. Elevated levels of lipid profile components can significantly increase the risk of cardiovascular disease, necessitating more aggressive treatment to mitigate this risk. Hypertriglyceridaemia, in particular, is a risk factor for pancreatitis.

To determine when referral to a lipid clinic is necessary, certain levels of total cholesterol, LDL cholesterol, and non-HDL cholesterol must be met. These figures are outlined in the learning point and serve as a guide for healthcare professionals in identifying patients who require specialist lipid care. With the help of lipid clinics, patients can receive tailored treatment plans to manage their lipid profiles and reduce their risk of cardiovascular disease.

Aortic Stenosis: Symptoms and Signs

Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to reduced blood flow from the heart to the rest of the body. One of the typical features of aortic stenosis is a systolic crescendo-decrescendo murmur that is loudest at the right upper sternal border. This murmur is usually heard during expiration and becomes softer when the patient stands. Additionally, the second heart sound is typically soft, and the apex beat is thrusting but not displaced.

To summarize, aortic stenosis can be identified by a combination of symptoms and signs, including a specific type of murmur, a soft second heart sound, and a thrusting apex beat.

Verapamil exhibits the strongest negative inotropic effect among calcium channel blockers.

Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

Driving can resume after hospital discharge if the patient has successfully undergone coronary angioplasty and there are no other disqualifying conditions. However, if the patient is a bus, taxi, or lorry driver, they must inform the DVLA and refrain from driving for a minimum of 6 weeks.

DVLA Guidelines for Cardiovascular Disorders and Driving

The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

Treatment Options for Raynaud’s Phenomenon

Raynaud’s phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow, leading to reduced blood flow and pain. The most commonly used drug for treatment is nifedipine, which causes vasodilatation and reduces the number and severity of attacks. However, patients may experience side-effects such as hypotension, flushing, headache, and tachycardia.

For those who cannot tolerate nifedipine, other agents such as nicardipine, amlodipine, or diltiazem can be tried. Limited evidence suggests that angiotensin receptor-blockers, fluoxetine, and topical nitrates may also provide some benefit. However, there is no evidence to support the use of antiplatelet agents.

In secondary Raynaud’s phenomenon, management of the underlying cause may help alleviate symptoms. Treatment options are similar to primary Raynaud’s phenomenon, with the addition of the prostacyclin analogue iloprost, which has shown to be effective in systemic sclerosis.

Overall, treatment options for Raynaud’s phenomenon aim to improve blood flow and reduce the frequency and severity of attacks. It is important to work with a healthcare provider to find the most effective treatment plan for each individual.

Understanding Prognostic Factors in Aortic Stenosis

Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to limited blood flow and various symptoms such as dyspnea, angina, and syncope. While patients may be asymptomatic for years, the prognosis for symptomatic aortic stenosis is poor, with a 2-year survival rate of only 50%. Sudden deaths can occur due to heart failure or other complications.

Valvular calcification and fibrosis are the primary causes of aortic stenosis, and the presence of calcification doesn’t have a direct impact on prognosis. However, mixed aortic valve disease, which includes aortic regurgitation, can increase mortality rates, particularly in severe cases.

Left ventricular failure is a significant prognostic factor in aortic stenosis, indicating late-stage hypertrophy and fibrosis. Patients with left ventricular failure have a poor prognosis both before and after surgery. Hypertension can also impact left ventricular remodelling and accelerate the progression of aortic stenosis, but it is not as significant a prognostic factor as left ventricular failure.

Electrocardiogram (ECG) changes, such as left ventricular hypertrophy, are common in patients with aortic stenosis but are not directly correlated with mortality risk. Understanding these prognostic factors can help healthcare providers better manage and treat patients with aortic stenosis.

Studies conducted recently have highlighted the noteworthy and swift decrease in blood pressure that can be attained through the reduction of salt consumption.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Antiplatelet Therapy for Non-ST-Elevation Acute Coronary Syndrome

The National Institute for Health and Care Excellence recommends dual therapy with aspirin and other antiplatelet for 12 months, followed by aspirin alone, for antiplatelet therapy after a non-ST-elevation acute coronary syndrome. However, the use of clopidogrel with aspirin increases the risk of bleeding, and there is no evidence of benefit beyond 12 months of the last event.

Medication Options for Angina and Hypertension

The National Institute for Health and Care Excellence (NICE) recommends considering treatment with an angiotensin-converting enzyme (ACE) inhibitor for secondary prevention in patients with stable angina and diabetes mellitus, as long as there are no contraindications. This should also be prescribed where there is co-existing hypertension, left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction (MI).

Amlodipine is a calcium-channel blocker which could be added to control hypertension; however, this patient’s blood pressure is normal on current therapy.

Diltiazem is a non-dihydropyridine calcium-channel blocker which can be used as an alternative first-line treatment in angina. This patient is already on atenolol and is well controlled.

Doxazosin is an alpha-blocker used in the management of hypertension. This patient’s blood pressure is within normal limits, so it is not currently indicated.

Nicorandil is an anti-anginal medication due to its vasodilatory properties which can be added or used as a monotherapy when symptoms of angina are not controlled with a beta-blocker or calcium-channel blocker or these are not tolerated. This patient’s symptoms are controlled on atenolol, so nicorandil is not indicated.

Renal Artery Stenosis and ACE Inhibitors

This man has diabetes and hypertension, along with mild symptoms of claudication and absent foot pulses, indicating arteriopathy. These factors suggest a diagnosis of renal artery stenosis (RAS), which can cause macrovascular disease and mild renal impairment.

When an antihypertensive medication was introduced, the patient’s renal function deteriorated, indicating that the drug was an ACE inhibitor. This is because hypertension in RAS is caused by the renin-angiotensin-aldosterone system trying to maintain renal perfusion. Inhibiting this system with ACE inhibitors can result in relative renal ischemia, leading to further deterioration of renal function.

In summary, patients with diabetes and hypertension who present with arteriopathy symptoms should be evaluated for RAS. The use of ACE inhibitors in these patients should be carefully monitored, as it can exacerbate renal impairment.

Venous Ulceration and Arterial Disease

Venous ulcerations are the most common type of ulcer affecting the lower extremities, often caused by venous insufficiency leading to venous congestion. Treatment involves controlling oedema, treating any infection, and compression, but compressive dressings or devices should not be used if arterial circulation is impaired. Therefore, it is crucial to identify any arterial disease, which can be done through the ankle-brachial pressure index. If indicated, a lower limb arteriogram may be necessary.

In cases where there is no clinical sign of infection, ruling out arterial insufficiency is more important than a bacterial swab. If there is a suspicion of deep vein thrombosis, a duplex or venogram is necessary to determine the need for anticoagulation. By identifying and addressing both venous ulceration and arterial disease, proper treatment can be administered to promote healing and prevent further complications.

If a patient has poorly controlled hypertension despite taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic, and their potassium level is above 4.5mmol/l, NICE recommends adding an alpha-blocker or seeking expert advice. In this case, as the patient is asthmatic, a beta-blocker is contraindicated, making an alpha-blocker the appropriate choice. However, if the patient’s potassium level was less than 4.5, a low-dose aldosterone antagonist could be considered as an off-license use. Referral for specialist assessment is only recommended if blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, which is not the case for this patient who is currently taking three antihypertensive agents.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Understanding Mitral Valve Prolapse: Symptoms, Causes, and Associated Conditions

Mitral valve prolapse is a condition where the leaflets of the mitral valve bulge in systole, affecting around 2-3% of the population. It can occur as an isolated entity or with heritable disorders of connective tissue. While most people are asymptomatic, some may experience symptoms such as anxiety, panic attacks, palpitations, syncope, or presyncope. The condition is also a risk factor for mitral regurgitation and carries a small risk of cerebral emboli and sudden death. Diagnosis is made through auscultation, with a mid-to-late systolic click and a late systolic murmur heard at the apex. Other heart conditions, such as atrial septal defect, aortic stenosis, mitral regurgitation, and mitral stenosis, have distinct murmurs that aid in diagnosis.

Raynaud’s phenomenon is a condition where the arteries in the fingers and toes constrict excessively in response to cold or emotional stress. It can be classified as primary (Raynaud’s disease) or secondary (Raynaud’s phenomenon) depending on the underlying cause. Raynaud’s disease is more common in young women and typically affects both sides of the body. Secondary Raynaud’s phenomenon is often associated with connective tissue disorders such as scleroderma, rheumatoid arthritis, or systemic lupus erythematosus. Other causes include leukaemia, cryoglobulinaemia, use of vibrating tools, and certain medications.

If there is suspicion of secondary Raynaud’s phenomenon, patients should be referred to a specialist for further evaluation. Treatment options include calcium channel blockers such as nifedipine as a first-line therapy. In severe cases, intravenous prostacyclin (epoprostenol) infusions may be used, which can provide relief for several weeks or months. It is important to identify and treat any underlying conditions that may be contributing to the development of Raynaud’s phenomenon. Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers or calcinosis. In rare cases, chilblains may also be present.

If a patient with angina doesn’t respond well to the first-line drug (such as a beta-blocker), the dose should be increased before adding another drug. The recommended dose of atenolol for angina is 100 mg daily, and a pulse rate of 72 bpm indicates inadequate beta-blockade. The starting dose of isosorbide mononitrate is 10 mg bd.

Angina pectoris can be managed through lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. NICE recommends using either a beta-blocker or a calcium channel blocker as first-line treatment, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker like amlodipine or modified-release nifedipine should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If initial treatment is ineffective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, long-acting nitrate, ivabradine, nicorandil, or ranolazine can be considered. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

Nitrate tolerance is a common issue for patients who take nitrates, leading to reduced efficacy. NICE advises patients who take standard-release isosorbide mononitrate to use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. However, this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate.

Understanding Symptoms of Aortic Stenosis

Aortic stenosis is a condition where the aortic valve becomes narrowed, leading to restricted blood flow from the heart. One of the most common symptoms of aortic stenosis is a murmur heard in the aortic area. This is often due to calcification of the valve. However, symptoms usually only appear when the stenosis becomes severe.

Patients with aortic stenosis may experience dyspnea on exertion, which is difficulty breathing during physical activity. More concerning symptoms include angina, syncope, or symptoms of heart failure. Angina is caused by left ventricular hypertrophy, while syncope is thought to be due to a failure to increase cardiac output during times of peripheral vasodilation and subsequent hypotension. It’s important to note that drugs that cause peripheral vasodilation, such as nitrates or ACE inhibitors, can increase the risk of syncope.

Dysphagia is a rare complication of left atrial hypertrophy due to mitral valve disease. Palpitations and transient ischemic attacks are not symptoms that are typically associated with aortic stenosis. The most common source of emboli with transient ischemic attacks is the carotids. Vertigo is not caused by aortic stenosis.

In summary, understanding the symptoms of aortic stenosis is crucial for early detection and treatment. If you experience any concerning symptoms, it’s important to speak with your healthcare provider.

Understanding Hypertension: Prevalence, Types, and Treatment

Hypertension, or high blood pressure, is a common condition that affects both men and women, with its prevalence increasing with age. Essential hypertension, which has no identifiable cause, is the most common type of hypertension, affecting 95% of hypertensive patients. However, indications for further evaluation include resistant hypertension and early, late, or rapid onset of high blood pressure.

Reducing blood pressure by an average of 12/6 mm Hg can significantly reduce the risk of stroke and coronary heart disease. Salt restriction, alcohol reduction, smoking cessation, aerobic exercise, and weight loss can also help reduce blood pressure by 3-5 mmHg, comparable to some drug treatments.

In severe cases, hypertension can lead to target organ damage, resulting in a hypertensive emergency. Malignant hypertension, which is diagnosed when papilloedema is present, can cause symptoms such as severe headache, visual disturbance, dyspnoea, chest pain, nausea, and neurological deficit.

Understanding hypertension and its types is crucial in managing and treating this condition. By implementing lifestyle changes and seeking medical attention when necessary, individuals can reduce their risk of hypertension-related complications.

The inheritance pattern of HOCM is autosomal dominant, meaning that if one parent has the condition, there is a 50 percent chance of passing on the mutated gene to their child.

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, nonspecific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.

Patients who have AF and stable CVD are typically prescribed anticoagulants while antiplatelets are discontinued. This is because such patients are at risk of stroke, as indicated by their CHADS-VASC score, which takes into account factors such as age, hypertension, and cardiovascular disease. Therefore, the patient in question needs to be treated accordingly. In this case, the patient should discontinue their antiplatelet medication and switch to oral anticoagulant monotherapy.

Managing Combination Antiplatelet and Anticoagulant Therapy

With the rise of comorbidity, it is becoming more common for patients to require both antiplatelet and anticoagulant therapy. However, this combination increases the risk of bleeding and may not be necessary in all cases. While there are no guidelines to cover every scenario, a recent review in the BMJ offers expert opinion on how to manage this situation.

For patients with stable cardiovascular disease who require an anticoagulant, it is recommended that they also receive an antiplatelet. However, if the patient has an indication for anticoagulant therapy, such as atrial fibrillation, it is best to prescribe anticoagulant monotherapy without the addition of antiplatelets.

In patients who have experienced an acute coronary syndrome or undergone percutaneous coronary intervention, there is a stronger indication for antiplatelet therapy. Typically, patients are given triple therapy (two antiplatelets and one anticoagulant) for four weeks to six months after the event, followed by dual therapy (one antiplatelet and one anticoagulant) for the remaining 12 months. However, the stroke risk in atrial fibrillation varies according to risk factors, so there may be variation in treatment from patient to patient.

If a patient on antiplatelets develops venous thromboembolism (VTE), they will likely be prescribed anticoagulants for three to six months. An ORBIT score should be calculated to determine the risk of bleeding. Patients with a low risk of bleeding may continue taking antiplatelets, while those with an intermediate or high risk of bleeding should consider stopping them.

Overall, managing combination antiplatelet and anticoagulant therapy requires careful consideration of the patient’s individual circumstances and risk factors.

Certain medications and substances can cause an increase in blood pressure, known as drug-induced hypertension. Non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 selective agents cause sodium and water retention, leading to elevated blood pressure. Sympathomimetic amines, such as amphetamines and pseudoephedrine, can also have this effect. Corticosteroids, particularly those with strong mineralocorticoid effects, can cause fluid retention and hypertension. Oral contraceptives may slightly raise blood pressure in some women. Venlafaxine increases levels of norepinephrine, contributing to hypertension. Cyclosporine and tacrolimus, used in transplant and autoimmune patients, can also have a significant effect on blood pressure. Caffeine and certain dietary supplements, such as ginseng, natural liquorice, and yohimbine, can also cause drug-induced hypertension.

Compression stockings should only be offered to patients with deep vein thrombosis who are experiencing post-thrombotic syndrome (PTS), which typically occurs 6 months to 2 years after the initial DVT and is characterized by chronic pain, swelling, hyperpigmentation, and venous ulcers. Apixaban is not appropriate for treating PTS, as it is used to treat acute DVT. Codeine may help with pain but doesn’t address the underlying cause. Hirudoid cream is not effective for treating PTS, as it is used for superficial thrombophlebitis. If conservative management is not effective, patients may be referred to vascular surgery for surgical treatment. Compression stockings are the first-line treatment for PTS, as they improve blood flow and reduce symptoms in the affected calf.

Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis

Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.

While compression stockings were previously recommended to reduce the risk of post-thrombotic syndrome in patients with DVT, Clinical Knowledge Summaries now advise against their use for this purpose. However, compression stockings are still recommended as a treatment for post-thrombotic syndrome. Other recommended treatments include keeping the affected leg elevated.

In summary, post-thrombotic syndrome is a potential complication of DVT that can cause a range of uncomfortable symptoms. While compression stockings are no longer recommended for prevention, they remain an important treatment option for those who develop the syndrome.

A significant proportion of individuals with resistant hypertension have an underlying secondary cause, such as Conn’s syndrome.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Statin Therapy and Creatine Kinase Levels

Prior to offering a statin, it is recommended to check creatine kinase (CK) levels in individuals with persistent generalised unexplained muscle pain, according to NICE guidelines. If CK levels are more than 5 times the upper limit of normal, statin therapy should not be started. The CK level should be rechecked after 7 days, and if it remains elevated to more than 5 times the upper limit of normal, a statin should not be initiated. However, if CK levels are elevated but less than 5 times the upper limit of normal, statin treatment can be initiated, but a lower dose is recommended. It is important to monitor CK levels in patients receiving statin therapy to ensure that muscle damage is not occurring.

Understanding Amlodipine: A Calcium-Channel Blocker and its Side-Effects

Amlodipine is a medication that belongs to the class of calcium-channel blockers. It works by inhibiting the inward displacement of calcium ions through the slow channels of active cell membranes. The primary effect of amlodipine is to relax vascular smooth muscle and dilate peripheral and coronary arteries. However, this medication is also associated with some side-effects due to its vasodilatory properties.

Common side-effects of amlodipine include flushing and headache, which usually subside after a few days. Another common side-effect is ankle swelling, which only partially responds to diuretics. In some cases, ankle swelling may be severe enough to warrant discontinuation of the drug. On the other hand, oedema is uncommon with losartan and not reported for any of the other options.

If you experience oedema due to calcium-channel blockers, it is important to manage it properly. Please refer to the external links for more information on how to manage this side-effect.

Possible Diagnosis of Infective Endocarditis and Criteria for Diagnosis

Infective endocarditis is a condition that involves inflammation of the heart valves caused by various organisms, including Streptococcus viridans. The lack of a dedicated blood supply to the valves reduces the immune response in these areas, making them susceptible to infection, especially if they are already damaged. A new or changing heart murmur, typical of aortic stenosis, may indicate the presence of infective endocarditis, particularly if accompanied by a fever.

To diagnose infective endocarditis, the Duke criteria require the presence of two major criteria, one major and three minor criteria, or five minor criteria. Major criteria include positive blood cultures with typical infective endocarditis microorganisms and evidence of vegetations on heart valves on an echocardiogram. Minor criteria include a predisposing factor such as a heart valve lesion or intravenous drug abuse, fever, embolism, immunological problems, or a single positive blood culture.

Immediate hospital admission is necessary for patients suspected of having infective endocarditis. Blood cultures should be taken before starting antibiotics, and an echocardiogram should be carried out urgently. While aortic stenosis is a common cause of heart murmurs, a new or changing murmur accompanied by a fever should raise suspicion of infective endocarditis.

Criteria for Diagnosing Infective Endocarditis

The current prescription of Atorvastatin alone is not sufficient for this patient. In addition to lipid-lowering therapy, he should also be offered an antihypertensive agent. However, it is important to note that due to his age and ethnicity, he should first be offered an ACE and/or angiotensin-II receptor antagonist. If he doesn’t have type 2 diabetes and is aged 55 years or over, or if he is of black African or African-Caribbean family origin and doesn’t have type 2 diabetes (of any age), calcium-channel blockers may be considered as the first-line antihypertensive agent. It is not appropriate to suggest that no treatment is required.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Understanding Warfarin: Mechanism of Action, Indications, Monitoring, Factors, and Side-Effects

Warfarin is an oral anticoagulant that has been widely used for many years to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. However, it has been largely replaced by direct oral anticoagulants (DOACs) due to their ease of use and lack of need for monitoring. Warfarin works by inhibiting epoxide reductase, which prevents the reduction of vitamin K to its active hydroquinone form. This, in turn, affects the carboxylation of clotting factor II, VII, IX, and X, as well as protein C.

Warfarin is indicated for patients with mechanical heart valves, with the target INR depending on the valve type and location. Mitral valves generally require a higher INR than aortic valves. It is also used as a second-line treatment after DOACs for venous thromboembolism and atrial fibrillation, with target INRs of 2.5 and 3.5 for recurrent cases. Patients taking warfarin are monitored using the INR, which may take several days to achieve a stable level. Loading regimens and computer software are often used to adjust the dose.

Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, drugs that displace warfarin from plasma albumin, and NSAIDs that inhibit platelet function. Warfarin may cause side-effects such as haemorrhage, teratogenic effects, skin necrosis, temporary procoagulant state, thrombosis, and purple toes.

In summary, understanding the mechanism of action, indications, monitoring, factors, and side-effects of warfarin is crucial for its safe and effective use in patients. While it has been largely replaced by DOACs, warfarin remains an important treatment option for certain patients.

Pain and Innervation in the Diaphragm, Lungs, and Pericardium

The diaphragm is innervated by the phrenic nerve, which only supplies the central portion of the muscle. Therefore, pain originating in the outer diaphragm will not be referred to the tip of the shoulder. Additionally, the lung parenchyma and visceral pleura are insensitive to pain, meaning that any discomfort felt in these areas is likely due to surrounding structures.

Pericarditis, inflammation of the pericardium surrounding the heart, can cause chest pain. However, this pain is typically relieved by sitting forward. This is because the pericardium is attached to the diaphragm and sternum, and sitting forward can reduce pressure on these structures, alleviating the pain. Understanding the innervation and sensitivity of these structures can aid in the diagnosis and management of chest pain.

The use of carvedilol and bisoprolol has been proven to decrease mortality in stable heart failure patients, while there is no evidence to support the use of other beta-blockers. NICE guidelines suggest that all individuals with heart failure should be prescribed both an ACE-inhibitor and a beta-blocker.

Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

Amiodarone, a class III antiarrhythmic drug, has the potential to impact various bodily systems such as the thyroid, liver, and lungs.

To ensure patient safety, it is recommended to conduct liver and thyroid function tests every six months. Before initiating amiodarone treatment, a chest x-ray is necessary, but it is not required routinely after treatment unless respiratory symptoms arise.

Adverse Effects and Drug Interactions of Amiodarone

Amiodarone is a medication used to treat irregular heartbeats. However, its use can lead to several adverse effects. One of the most common adverse effects is thyroid dysfunction, which can manifest as either hypothyroidism or hyperthyroidism. Other adverse effects include corneal deposits, pulmonary fibrosis or pneumonitis, liver fibrosis or hepatitis, peripheral neuropathy, myopathy, photosensitivity, a slate-grey appearance, thrombophlebitis, injection site reactions, bradycardia, and lengthening of the QT interval.

It is also important to note that amiodarone can interact with other medications. For example, it can decrease the metabolism of warfarin, leading to an increased INR. Additionally, it can increase digoxin levels. Therefore, it is crucial to monitor patients closely for adverse effects and drug interactions when using amiodarone. Proper management and monitoring can help minimize the risks associated with this medication.

Managing White-Coat Hypertension with Home Blood Pressure Monitoring

According to current NICE guidance, hypertension should be diagnosed in patients with a clinic BP of 140/90 mmHg or greater and either average daily ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) readings of greater than 135/85. However, if a patient’s home readings are within normal range, their elevated clinic BP is likely due to white-coat hypertension. In such cases, further assessment with ABPM is unnecessary. Monthly BP reviews with the practice nurse are also unnecessary if HBPM readings are normal. Treatment is not recommended based on clinic readings alone, and specialist referral is not needed if HBPM readings are within normal range. Home blood pressure monitoring can effectively manage white-coat hypertension.

If the ABPM indicates an average blood pressure below the threshold, NICE suggests conducting blood pressure measurements on the patient every 5 years.

NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines recommend classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. This is because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure and can help prevent overdiagnosis.

To diagnose hypertension, NICE recommends measuring blood pressure in both arms and repeating the measurements if there is a difference of more than 20 mmHg. If the difference remains, subsequent blood pressures should be recorded from the arm with the higher reading. NICE also recommends taking a second reading during the consultation if the first reading is above 140/90 mmHg. ABPM or HBPM should be offered to any patient with a blood pressure above this level.

If the blood pressure is above 180/120 mmHg, NICE recommends admitting the patient for specialist assessment if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury. Referral is also recommended if a phaeochromocytoma is suspected. If none of these apply, urgent investigations for end-organ damage should be arranged. If target organ damage is identified, antihypertensive drug treatment may be started immediately. If no target organ damage is identified, clinic blood pressure measurement should be repeated within 7 days.

ABPM should involve at least 2 measurements per hour during the person’s usual waking hours, with the average value of at least 14 measurements used. If ABPM is not tolerated or declined, HBPM should be offered. For HBPM, two consecutive measurements need to be taken for each blood pressure recording, at least 1 minute apart and with the person seated. Blood pressure should be recorded twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days. The measurements taken on the first day should be discarded, and the average value of all the remaining measurements used.

Interpreting the results, ABPM/HBPM above 135/85 mmHg (stage 1 hypertension) should be

Myocardial infarction (MI) is a serious condition that requires proper management to prevent further complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the secondary prevention of MI. Patients who have had an MI should be offered dual antiplatelet therapy, ACE inhibitors, beta-blockers, and statins. Lifestyle changes such as following a Mediterranean-style diet and engaging in regular exercise are also recommended. Sexual activity may resume after four weeks, and PDE5 inhibitors may be used after six months, but caution should be exercised in patients taking nitrates or nicorandil.

Dual antiplatelet therapy is now the standard treatment for most patients who have had an acute coronary syndrome. Ticagrelor and prasugrel are now more commonly used as ADP-receptor inhibitors. The NICE Clinical Knowledge Summaries recommend adding ticagrelor to aspirin for medically managed patients and prasugrel or ticagrelor for those who have undergone percutaneous coronary intervention. The second antiplatelet should be stopped after 12 months, but this may be adjusted for patients at high risk of bleeding or further ischaemic events.

For patients who have had an acute MI and have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist such as eplerenone should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy. Proper management and adherence to these guidelines can significantly reduce the risk of further complications and improve the patient’s quality of life.

Statins are drugs that inhibit the action of HMG-CoA reductase, which is the enzyme responsible for cholesterol synthesis in the liver. However, they can cause adverse effects such as myopathy, liver impairment, and an increased risk of intracerebral hemorrhage in patients with a history of stroke. Statins should not be taken during pregnancy or in combination with macrolides. NICE recommends statins for patients with established cardiovascular disease, a 10-year cardiovascular risk of 10% or higher, type 2 diabetes mellitus, or type 1 diabetes mellitus with certain criteria. It is recommended to take statins at night, especially simvastatin, which has a shorter half-life than other statins. NICE recommends atorvastatin 20 mg for primary prevention and atorvastatin 80 mg for secondary prevention.

Management of Hypertension in Primary Care

Referring a patient to the hospital for hypertension without suspicion of accelerated hypertension is inappropriate. According to the updated NICE guidelines on Hypertension (NG136) in September 2019, immediate treatment should only be considered if the blood pressure is equal to or greater than 180/120 mmHg. In this case, it is recommended to bring the patient back for ambulatory monitoring or record their home blood pressure readings for at least four days. Repeating blood pressure with the nurse is no longer preferred, as ambulatory or home readings are considered better. The presence of a fungal nail infection is irrelevant, but it may be necessary to check the patient’s fasting blood sugar or HbA1c to rule out diabetes. When answering AKT questions, it is important to consider the bigger picture and remember that the questions test knowledge of national guidance and consensus opinion, not just the latest NICE guidance.

Understanding Alpha Blockers

Alpha blockers are medications that are commonly prescribed for the treatment of benign prostatic hyperplasia and hypertension. These drugs work by blocking the alpha-adrenergic receptors in the body, which can help to relax the smooth muscles in the prostate gland and blood vessels, leading to improved urine flow and lower blood pressure. Some examples of alpha blockers include doxazosin and tamsulosin.

While alpha blockers can be effective in managing these conditions, they can also cause side effects. Some of the most common side effects of alpha blockers include postural hypotension, drowsiness, dyspnea, and cough. Patients who are taking alpha blockers should be aware of these potential side effects and should speak with their healthcare provider if they experience any symptoms.

Cardiovascular Complications in Ankylosing Spondylitis

Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints. However, it can also lead to cardiovascular complications. The most common complication is aortic regurgitation, which occurs due to inflammation of the ascending aorta. On the other hand, mitral regurgitation is not typically associated with ankylosing spondylitis and is usually caused by congenital conditions or cardiomyopathies. Aortic stenosis is also not commonly associated with ankylosing spondylitis, as it is usually caused by age-related calcification or congenital bicuspid valve. Similarly, mitral stenosis is more commonly associated with rheumatic heart disease than ankylosing spondylitis. Tricuspid stenosis is a rare cardiac defect that is usually associated with rheumatic fever. Therefore, it is important for individuals with ankylosing spondylitis to be aware of the potential cardiovascular complications and to seek medical attention if any symptoms arise.

Serum levels of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) can be measured to assess the likelihood of heart failure in patients. NT-proBNP is the inactive prohormone of BNP and is released from the left ventricle in response to ventricular strain. It acts to increase renal excretion of water and sodium, and relax vascular smooth muscle causing vasodilation.

BNP measurements are recommended for patients with suspected heart failure who have not had a previous myocardial infarction. Elevated BNP levels (>400) indicate a poor prognosis and require an urgent referral for echocardiography and specialist assessment. However, normal BNP levels do not confirm the absence of heart failure, as levels may be elevated due to other conditions such as left ventricular hypertrophy, pulmonary hypertension, or renal impairment.

NICE guidelines suggest that BNP measurements are not necessary for patients with suspected heart failure who have had a previous myocardial infarction, as urgent referral and assessment are required regardless of BNP levels. BNP levels may also be affected by medications such as ACE inhibitors and beta-blockers, as well as obesity.

Overall, BNP measurements can be a useful tool in assessing the likelihood of heart failure, but should be interpreted in conjunction with other clinical findings and patient history.

B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.

BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.

Understanding Angina Symptoms: What to Look Out For

Angina is a type of chest pain that occurs when the heart muscle doesn’t receive enough oxygen-rich blood. Here are some common symptoms associated with angina:

Radiation to the throat and jaw: Chest pain that radiates to the throat and jaw is typical of angina.

Prolonged pain: Anginal pain is typically exertional and quickly relieved by rest or glyceryl trinitrate (GTN spray) within around five minutes. It is not typically prolonged.

Associated dizziness: Pain associated with palpitations or dizziness is less likely to be angina than other attributable causes.

Associated shortness of breath: Shortness of breath can occur in both cardiac and pulmonary causes of chest pain and so is not specific to angina.

Pain associated with taking a breath in: Pain associated with breathing is likely to be associated with pulmonary or musculoskeletal causes of chest pain, rather than angina.

It’s important to note that these symptoms can also be indicative of other health issues, so it’s always best to consult with a healthcare professional if you experience any chest pain or discomfort.

For individuals with heart failure with reduced ejection fraction who continue to experience symptoms, it is recommended to add a mineralocorticoid receptor antagonist, such as spironolactone, to their current treatment plan of an ACE inhibitor (or ARB) and beta-blocker. Prior to starting or increasing the dosage of a mineralocorticoid receptor antagonist, it is important to monitor serum sodium, potassium, renal function, and blood pressure. Amiodarone is not typically used as a first line treatment for heart failure and should only be prescribed in consultation with a cardiology specialist. Digoxin may be recommended if heart failure worsens or becomes severe despite initial treatment, but it is important to note that a mineralocorticoid receptor antagonist should be prescribed first. Ivabradine may also be used in heart failure, but it should not be prescribed if the patient’s heart rate is below 75 and is not typically used as a first line treatment.

Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.