To ensure effective symptom control, it is important to prescribe modified release calcium channel blockers by their specific brand names, as their release characteristics can vary. Therefore, it is necessary to maintain consistency in the brand prescribed.

Prescribing Guidance for Healthcare Professionals

Prescribing medication is a crucial aspect of healthcare practice, and it is essential to follow good practice guidelines to ensure patient safety and effective treatment. The British National Formulary (BNF) provides guidance on prescribing medication, including the recommendation to prescribe drugs by their generic name, except for specific preparations where the clinical effect may differ. It is also important to avoid unnecessary decimal points when writing numbers, such as prescribing 250 ml instead of 0.25 l. Additionally, it is a legal requirement to specify the age of children under 12 on their prescription.

However, there are certain drugs that should be prescribed by their brand name, including modified release calcium channel blockers, antiepileptics, ciclosporin and tacrolimus, mesalazine, lithium, aminophylline and theophylline, methylphenidate, CFC-free formulations of beclomethasone, and dry powder inhaler devices. By following these prescribing guidelines, healthcare professionals can ensure safe and effective medication management for their patients.

Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

Diagnostic Tests for Aortic Stenosis

Aortic stenosis is a serious condition that requires prompt diagnosis and treatment. One of the most important diagnostic tests for aortic stenosis is an echocardiogram, which can provide valuable information about the extent of the stenosis and whether surgery is necessary. In addition, an angiogram may be performed to assess the presence of ischaemic heart disease, which often occurs alongside aortic stenosis.

Other diagnostic tests that may be used to evaluate aortic stenosis include a chest X-ray, which can reveal cardiac enlargement or calcification of the aortic ring, and an electrocardiogram, which may show evidence of left ventricular hypertrophy. Exercise testing is not recommended for symptomatic patients, but may be useful for unmasking symptoms in physically active patients or for risk stratification in asymptomatic patients with severe disease.

While lung function testing is not typically part of the routine workup for aortic stenosis, it is important for patients to be aware of the risks associated with rigorous exercise, as sudden death can occur in those with severe disease. Overall, a comprehensive diagnostic approach is essential for accurately assessing the extent of aortic stenosis and determining the most appropriate course of treatment.

Management of Statin-Induced Elevated Creatine Kinase Levels

When a patient taking statins presents with elevated creatine kinase levels, it is important to consider other potential causes such as underlying muscle disorders or hypothyroidism. If the creatine kinase level is more than five times the upper limit of normal, the statin should be stopped immediately and renal function should be checked. Creatine kinase levels should be monitored every two weeks.

If symptoms resolve and creatine kinase levels return to normal, the statin can be reintroduced at the lowest dose with close monitoring. If creatine kinase levels are less than five times the upper limit of normal and the patient experiences muscular symptoms, the statin can be continued but closely monitored. If symptoms are severe or creatine kinase levels increase, the statin should be stopped.

If the patient is asymptomatic despite elevated creatine kinase levels, the statin can be continued with the patient advised to report any muscular symptoms immediately. Creatine kinase levels should be monitored to ensure they do not increase. By following these guidelines, healthcare providers can effectively manage statin-induced elevated creatine kinase levels.

Furosemide is the appropriate choice for managing symptoms in individuals with heart failure with preserved ejection fraction using loop diuretics. Spironolactone is not recommended for this purpose. In cases of heart failure with reduced ejection fraction, mineralocorticoid receptor antagonists should be considered along with an ACE inhibitor (or ARB) and beta-blocker if symptoms persist.

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.

Managing Abnormal Results when Initiating or Increasing ACE-I Dose

When initiating or increasing the dose of an ACE-I, it is important to monitor for any abnormal results. According to NICE, a slight increase in serum creatinine and potassium is expected. However, if the eGFR reduction is 25% or less (or serum creatinine increase of less than 30%), no modification to the treatment regime is needed, as long as no further reductions occur.

If the eGFR decrease is 25% or more, it is important to consider other potential causes such as volume depletion, other nephrotoxic drugs, or vasodilators. If none of these are applicable, it may be necessary to stop the ACE-I or reduce the dose to a previously tolerated level. It is recommended to recheck levels in 5-7 days to ensure that the treatment is effective and safe for the patient. By closely monitoring and managing abnormal results, healthcare professionals can ensure that patients receive the best possible care when taking ACE-Is.

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.

When taking warfarin, it is important to monitor INR levels carefully when also taking fluconazole due to their interaction. Fluconazole can cause an increase in INR. However, medications such as amikacin, vancomycin, clindamycin, and nitrofurantoin do not affect INR levels.

Interactions of Warfarin

Warfarin is a commonly used anticoagulant medication that requires careful monitoring due to its interactions with other drugs and medical conditions. Some general factors that can potentiate warfarin include liver disease, drugs that inhibit platelet function such as NSAIDs, and cranberry juice. Additionally, drugs that either inhibit or induce the P450 system can affect the metabolism of warfarin and alter the International Normalized Ratio (INR), which measures the effectiveness of the medication.

Drugs that induce the P450 system, such as antiepileptics and barbiturates, can decrease the INR, while drugs that inhibit the P450 system, such as antibiotics and SSRIs, can increase the INR. Other factors that can affect the metabolism of warfarin include chronic alcohol intake, smoking, and certain medical conditions. It is important for healthcare providers to be aware of these interactions and monitor patients closely to ensure safe and effective use of warfarin.

According to NICE guidelines, the initial test for patients with suspected chronic heart failure should be an NT-proBNP test. This should be done in conjunction with obtaining an ECG, and is recommended for patients who have not previously experienced a myocardial infarction.

Diagnosis of Chronic Heart Failure

Chronic heart failure is a serious condition that requires prompt diagnosis and management. In 2018, the National Institute for Health and Care Excellence (NICE) updated its guidelines on the diagnosis and management of chronic heart failure. According to the new guidelines, all patients should undergo an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation, regardless of whether they have previously had a myocardial infarction or not.

Interpreting the NT-proBNP test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks.

BNP is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis. The table above shows the different levels of BNP and NTproBNP and their corresponding interpretations.

It is important to note that certain factors can alter the BNP level. For instance, left ventricular hypertrophy, ischaemia, tachycardia, and right ventricular overload can increase BNP levels, while diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists can decrease BNP levels. Therefore, it is crucial to consider these factors when interpreting the NT-proBNP test.

Cardiac Abnormalities in Marfan Syndrome

Marfan syndrome is an inherited connective tissue disorder that affects various systems in the body. The most common cardiac complication is aortic root dilatation, which occurs in 70% of patients. Mitral valve prolapse is the second most common abnormality, affecting around 60% of patients. Beta-blockers can help reduce the rate of aortic dilatation and the risk of rupture. Aortic dissection, although not the most common abnormality, is a major diagnostic criterion of Marfan syndrome and can result from weakening of the aortic media due to root dilatation. Aortic regurgitation is less common than mitral regurgitation but can occur due to progressive aortic root dilatation and connective tissue abnormalities. Mitral annular calcification is more frequent in Marfan syndrome than in the general population but is not included in the diagnostic criteria.

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.

Tips for a Heart-Healthy Diet after a Heart Attack

Following a heart attack, it is important to adopt a healthier overall diet to reduce the risk of future heart problems. Unhealthy diets have been attributed to up to 30% of all deaths from coronary heart disease (CHD). While reducing fat intake is important, exercise also plays a crucial role in maintaining heart health.

Including canned and frozen fruits and vegetables in your diet is just as beneficial as fresh produce. A Mediterranean diet, which includes many protective elements for CHD, is recommended. Replacing butter with olive oil and mono-unsaturated margarine, such as those made from rape-seed or olive oil, is a healthier option. Organic butter is not any better for heart health than non-organic butter.

To reduce cholesterol intake, it is recommended to eat less red meat and replace it with poultry. Margarine containing sitostanol ester may also help reduce cholesterol intake. Adding plant sterol to margarine has been shown to reduce serum low-density lipoprotein cholesterol. Eating more fish, including oily fish, at least once a week is also recommended.

Switching to whole-grain bread instead of white bread and eating more root vegetables and green vegetables is also beneficial. Lastly, it is important to eat fruit every day. By following these tips, you can maintain a heart-healthy diet and reduce the risk of future heart problems.

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.

Common Cardiac Arrhythmias and Their Characteristics

Acute atrial fibrillation is characterized by a sudden onset within the past 48 hours and may be triggered by excessive alcohol or caffeine intake. An ECG is necessary for diagnosis. Atrial flutter is less common than atrial fibrillation and typically presents with a rapid, irregular or regular pulse with a ventricular rate of approximately 150 beats per minute. Extrasystoles are extra heartbeats that disrupt the normal rhythm of the heart and can originate from either the atria or ventricles. Sinus arrhythmia is a common occurrence in children and young adults and involves cyclic changes in heart rate during breathing. Sinus tachycardia is a physiological response to various stimuli such as fever, anxiety, pain, exercise, and hyperthyroidism, and is characterized by a regular heart rate of over 100 beats per minute.

Insomnia may be caused by beta-blockers.

Beta-blockers are a class of drugs that are primarily used to manage cardiovascular disorders. They have a wide range of indications, including angina, post-myocardial infarction, heart failure, arrhythmias, hypertension, thyrotoxicosis, migraine prophylaxis, and anxiety. Beta-blockers were previously avoided in heart failure, but recent evidence suggests that certain beta-blockers can improve both symptoms and mortality. They have also replaced digoxin as the rate-control drug of choice in atrial fibrillation. However, their role in reducing stroke and myocardial infarction has diminished in recent years due to a lack of evidence.

Examples of beta-blockers include atenolol and propranolol, which was one of the first beta-blockers to be developed. Propranolol is lipid-soluble, which means it can cross the blood-brain barrier.

Like all drugs, beta-blockers have side-effects. These can include bronchospasm, cold peripheries, fatigue, sleep disturbances (including nightmares), and erectile dysfunction. There are also some contraindications to using beta-blockers, such as uncontrolled heart failure, asthma, sick sinus syndrome, and concurrent use with verapamil, which can precipitate severe bradycardia.

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.

Management of Isolated Systolic Hypertension: Drug Options and Considerations

Isolated systolic hypertension, characterized by elevated systolic blood pressure and normal diastolic blood pressure, is managed similarly to systolic plus diastolic hypertension. Amlodipine, a dihydropyridine calcium-channel blocker, is the preferred first-line drug for treating isolated systolic hypertension in patients over 55 years old.

Before starting any medication, a new diagnosis of hypertension should be confirmed through ambulatory blood pressure monitoring or home blood pressure monitoring. Additionally, an assessment for evidence of end-organ damage and 10-year cardiovascular risk should be conducted, along with a discussion about modifiable risk factors such as diet, exercise, sodium intake, alcohol consumption, caffeine, and smoking.

Indapamide, a thiazide diuretic, is typically used as a second or third step in the treatment protocol. However, it may exacerbate gout and worsen urinary problems.

Beta-blockers, such as atenolol, were previously recommended as second-line treatment for hypertension. However, they can cause hyperglycemia and are now at step 4 of the management plan. Beta-blockers are also contraindicated in asthma, making them unsuitable for some patients.

Doxazosin, which is at step 4 of the hypertension management plan, may cause urinary incontinence and is not appropriate for all patients.

Valsartan, an angiotensin 2 receptor blocker, is a first-line option for patients under 55 years old, along with an angiotensin-converting enzyme (ACE) inhibitor. It may be added at step 2 if necessary for patients over 55 years old.

Understanding Nitrates and Their Effects on the Body

Nitrates are a type of medication that can cause blood vessels to widen, which is known as vasodilation. They are commonly used to manage angina and treat heart failure. One of the most frequently prescribed nitrates is sublingual glyceryl trinitrate, which is used to relieve angina attacks in patients with ischaemic heart disease.

The mechanism of action for nitrates involves the release of nitric oxide in smooth muscle, which activates guanylate cyclase. This enzyme then converts GTP to cGMP, leading to a decrease in intracellular calcium levels. In the case of angina, nitrates dilate the coronary arteries and reduce venous return, which decreases left ventricular work and reduces myocardial oxygen demand.

However, nitrates can also cause side effects such as hypotension, tachycardia, headaches, and flushing. Additionally, many patients who take nitrates develop tolerance over time, which can reduce their effectiveness. To combat this, the British National Formulary recommends that patients who develop tolerance take the second dose of isosorbide mononitrate after 8 hours instead of 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness. It’s important to note that this effect is not seen in patients who take modified release isosorbide mononitrate.

Patients who have undergone catheter ablation for atrial fibrillation still need to continue long-term anticoagulation based on their CHA2DS2-VASc score. In the case of this patient, who has a CHA2DS2-VASc score of 2 due to age and past medical history of diabetes, it is appropriate to continue anticoagulation.

Amiodarone is typically used for rhythm control of atrial fibrillation, but it is not indicated in this patient who has undergone catheter ablation and has no obvious recurrence of AF.

Beta-blockers and diltiazem are used for rate control of atrial fibrillation, but medication for AF is not indicated in this patient.

Anticoagulation can be stopped after 4 weeks post catheter ablation only if the CHA2DS2-VASc score is 0.

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.

For primary prevention of cardiovascular disease, the recommended treatment is atorvastatin 20 mg, while for secondary prevention, atorvastatin 80 mg is recommended. Simvastatin used to be the first-line option, but atorvastatin is now preferred due to its higher intensity and lower risk of myopathy at high doses. Before starting statin treatment, it is important to check liver function tests, which in this case were normal. According to the BNF, atorvastatin 20 mg is appropriate for patients with chronic kidney disease. It is not recommended to use ezetimibe or fenofibrate as first-line options for managing cholesterol.

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.

Prohibited Substances in Sports

Beta-blockers and diuretics are among the substances prohibited in certain sports. In billiards and archery, the use of beta-blockers is not allowed as they can enhance performance by reducing anxiety and tremors. On the other hand, diuretics are generally prohibited as they can be used as masking agents to hide the presence of other banned substances. It is important to note that diuretics can be found in some combination products, such as Cozaar-Comp which contains hydrochlorothiazide. Athletes should be aware of the substances they are taking and ensure that they are not violating any anti-doping regulations.

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

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.

This pertains to the utilization of statins for initial prevention, as opposed to the present NICE guidelines for hypertension.

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

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.

Moderate to severe aortic stenosis is a contraindication for ACE inhibitors like ramipril due to the potential risk of reducing coronary perfusion pressure and causing cardiac ischemia. Therefore, the patient should stop taking ramipril until cardiology review. However, bisoprolol, which reduces cardiac workload by inhibiting β1-adrenergic receptors, is safe to use in the presence of aortic stenosis. Digoxin, which improves cardiac contractility, is also safe to use unless there are defects in the cardiac conduction system. Metformin should be used with caution in patients with chronic heart failure but is not contraindicated in those with valvular disease. Quinine is also safe to use in the presence of aortic stenosis but should be stopped if there are defects in the cardiac conduction system.

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 Vascular Dementia

Vascular dementia is a type of cognitive decline that includes multi-infarct dementia and other forms of intellectual deterioration in individuals at high risk of atherosclerosis. Unlike Alzheimer’s, it is characterized by a stepwise progression, although it may also present as a steadily progressive dementia. A history of risk factors such as transient ischemic attacks (TIAs), stroke, hypertension, smoking, and hypercholesterolemia can raise suspicion of vascular dementia.

Aggression without significant short-term memory loss is more commonly associated with frontal lobe dementia, while Parkinsonian features are typical of Lewy body dementia. Understanding the different types of dementia and their associated symptoms can help individuals and their loved ones better manage the condition and seek appropriate medical care.

When it comes to reducing the risk of stroke in patients with AF, DOACs should be the first option. In the case of this patient, her CHA2DS2-VASc score is 3, with 2 points for the transient ischaemic attack and 1 point for being female. Therefore, it is recommended that she be given anticoagulation treatment with DOACs, which are now preferred over warfarin.

Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

Carotid Duplex Ultrasonography for Atherosclerotic Stenosis

Whilst carotid duplex ultrasonography may not be arranged directly from primary care, it is important for healthcare professionals to have an understanding of investigations that may be arranged by secondary care and to be able to discuss this in more general terms with their patients, including indications. This is particularly relevant for patients who have experienced amaurosis fugax caused by internal carotid artery atherosclerotic stenosis, which may also present with temporary paresis, aphasia, or sensory deficits. Fundoscopic examination may reveal bright yellow cholesterol emboli in patients with retinal involvement. The investigation to identify the significant stenosis or occlusive lesion usually greater than 70% is carotid duplex ultrasonography.

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.