10: CARDIOLOGY

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CHAPTER 10 CARDIOLOGY

Primary prevention of coronary heart disease
Hypertension
Cholesterol
Intermittent claudication
Chest pain
Angina
Acute myocardial infarction (MI)
Postmyocardial infarction
Heart failure
Raynaud’s phenomenon
Funny turns
Palpitations

PRIMARY PREVENTION OF CORONARY HEART DISEASE

Primary prevention relates to individuals who have not developed symptomatic cardiovascular disease (CVD) or other major atherosclerotic disease, such as stroke/TIA or peripheral vascular disease.

In order to calculate a patient’s CVD risk the following information is required:

• Gender.
• Age.
• Smoking status.
• Total cholesterol.
• HDL cholesterol.
• Blood pressure.

The presence or abTof diabetes mellitus is now obsolete when calculating primary coronary/stroke risk. Patients with diabetes should be considered suitable for secondary prevention measures (see Tip Box below).

Apply this information to the graphs on pp. 147–148 to calculate the 10-year risk of developing CVD. Alternatively, use the computer CHD/CVD risk calculator in the clinical system holding the patient’s medical record.

Tip

Patients >50 years old with a 10-year CVD risk >20% should take aspirin 75 mg od unless contraindicated. Patients <80 years old with a 10-year CVD risk >20% and a serum total cholesterol >3.5 mmol/l should, in addition, be prescribed a statin.

General lifestyle advice for prevention of CVD

• Stop smoking (see p. 313).
• Dietary advice:

– aim for ideal weight (see obesity, p. 113)
– reduce dietary fats (see cholesterol, p. 151)
– consume five portions of fruit or vegetables per day.

• Encourage exercise: recommend at least 20 minutes of brisk exercise three times per week.
• Encourage stress reduction (see anxiety, p. 294).
• Avoid excessive alcohol intake (>14 units per week for women and >21 units for men).

Risk factors for CVD

• Male.
• Age >50 years.
• South Asian/Afro-Caribbean race.
• Smoking.

JOINT BRITISH SOCIETIES’ CVD RISK-PREDICTION CHARTS

image image

Reproduced with permission from Professor P. Durrington, University of Manchester. Heart 2005; 91(Suppl V): VI–V52, copyright University of Manchester. These graphs underestimate the CVD risk in patients with a strong family history of premature CVD, and also those of Afro–Caribbean or South Asian origin.

• Obesity.
• Hypertension.
• Diabetes.
• Hyperlipidaemia.
• Other atheromatous disease (CVA/TIA, peripheral vascular disease).
• Family history of premature atheromatous disease.

HYPERTENSION

Hypertension affects approximately 15% of the population. It is asymptomatic unless extremely high. It can be managed almost entirely in general practice. The following advice is based on the British Hypertension Society’s Guidelines 2004.

Diagnosis

The new hypertensive.

On finding a raised blood pressure for the first time in a patient, the path described below can be followed.

• <139/89: no treatment, no follow-up (<130/80 in diabetics).
• >160/100: treat if consistently above this level on four or more consecutive readings over 2 weeks.

Tip

Ask the practice nurse to repeat the readings.

• Between 140/90 and 160/99: repeat BP reading four times over 3–6 weeks.

Diastolic BP of >120 and rising on subsequent examinations suggests malignant hypertension. Urgent referral or hospital admission is necessary.

After the fourth BP reading

• If any diastolic BP is <90 and the systolic is <140, no treatment is indicated (<130/80 in diabetics).
• If the BP is persistently in the range 140–160/90–99:

– treatment is indicated if the patient is at high risk of cardiovascular disease (>20% 10-year CVD risk, see p. 146), or if there is evidence of target organ damage, as suggested by:

image left ventricular hypertrophy (CXR or ECG)
image transient ischaemic attacks
image previous stroke, angina or MI
image renal impairment (raised creatinine, proteinuria/haematuria)
image peripheral vascular disease
image hypertensive retinopathy.
– treatment is not indicated if there is no evidence of target organ disease, and the 10-year CVD risk is <20%. Check the BP and reassess the CHD risk annually.

Initial investigations

• Blood tests: C&Es, fasting lipid profile to include total cholesterol and HDL cholesterol, urate, fasting plasma glucose.
• Urine tests: protein.
• ECG: for left ventricular hypertrophy.
• Patients under 35 years old: 24-hour urinary metadrenaline for phaeochromocytoma.
• Examine for retinopathy, abdominal aortic aneurysm, renal bruit, absent foot pulses.

Management

Advice.

All hypertensives should be given advice on non-pharmacological methods.

See general lifestyle advice (p. 146).

Prescribing

• In patients over 55 or Black, initiate treatment with a calcium-channel blocker, e.g. amlodipine 5–10 mg daily.
• In patients under 55 or non-Black, initiate treatment with an ACE inhibitor, e.g. perindopril 2–8 mg daily.
• If the above are contraindicated, use a diuretic, e.g. bendroflumethiazide 2.5 mg daily in the over-65s/Black population or a beta-blocker, e.g. atenolol 50–100 mg daily in the under-65/non-Black population.
• Start aspirin 75 mg od in patients over 50 years old with satisfactory blood pressure control, if there is target organ damage or diabetes or established cardiovascular disease, or if the 10-year CVD risk is >20%.
• Start a statin (e.g. simvastatin 40 mg) in patients under 80 years old when serum total cholesterol is >3.5 mmol/l and the 10-year CVD risk is >20%, or if there is established CVD.

Follow-up

• Frequency of follow-up should be 4-weekly initially, unless there is a need to achieve more urgent control (e.g. BP >200/120).

Tip

If there are unacceptable side-effects, change to an alternative drug.

• Aim for BP of <140/85 ideally, but <150/90 is acceptable (<130/80 in diabetics).
• If control is not achieved, add a second drug from another class.
• If control is still not achieved, either add a third drug or consider referral (see below).
• Once control is achieved, follow up with BP check every 6 months. Arrange annual urinalysis for protein, and check C&Es and fasting blood sugar. Recalculate CVD risk every year.

Reasons for referral

• Malignant hypertension.
• Secondary hypertension (raised creatinine or proteinuria).
• Refractory hypertension (difficult to treat with two or more drugs).
• Hypertension of sudden onset.
• Hypertension that is worsening despite treatment.
• Hypertension under age 35 years with multiple cardiovascular risk factors.
• Pregnancy.

Stopping antihypertensives.

If BP is consistently <130/80 and there is no evidence of target organ disease, antihypertensives can be gradually withdrawn.

Regular monitoring is essential and should be long-term.

Administration

Quality and Outcomes Framework for Hypertension

• Check the blood pressure of patients on the hypertension register 6-monthly.
• Achieve a blood pressure of 150/90 or below.
• Record the smoking annually.
• Offer smoking cessation to hypertensive smokers annually.

CHOLESTEROL

High cholesterol is principally a risk factor for the development of cardiovascular disease. GPs should consider the level of their patients’ cholesterol when monitoring overall coronary risk.

Diagnosis

Test serum cholesterol if:

• The patient is at high risk of CHD:

– hypertensive
– diabetic
– has established atheromatous disease (angina, MI, CABG, CVA, TIA, peripheral vascular disease)
– combination of risk factors, including smoking, obesity, lack of exercise
– family history of heart disease: first-degree relative suffering coronary death under age 50 for male relative, age 60 for female relative.

• Family history of hyperlipidaemia.
• Patient’s request.

Interpreting results

• Measurements of both total cholesterol and HDL cholesterol should be made.
• Readings should be applied to the Joint British Societies Coronary Risk Prediction Chart to assess 10-year coronary risk (see pp. 147–148).
• Very high serum cholesterol (say, >10) suggests a familial hyperlipidaemia.
• Serum cholesterol is elevated in:

– diabetes mellitus
– nephrotic syndrome
– hypothyroidism
– pregnancy.

Management

Advice.

Give dietary advice:

• to achieve ideal weight
• to reduce overall fat intake
• to reduce saturated fat intake.

Dietary measures

(Send the patient to the practice nurse for advice.)

• Explain the role of diet in heart disease and the need for change.
• Measure weight and height and calculate body mass index from the formula BMI = weight (kg) ÷ (height (m))2. Aim for a BMI of <25 for men and <23 for women.
• Ask the patient to keep an accurate dietary diary for 1 week.
• Review the diary with the patient, identifying sources of saturated fat intake.
• Suggest low-fat alternatives, aiming to substitute polyunsaturated fats or carbohydrates for saturated fats.
• Encourage compliance. Offer a follow-up appointment.

• Give advice on other risk factors (see p. 146).
• In the absence of established cardiovascular disease, treat patients under 80 years old with a statin if the 10-year CVD risk is >20% (see p. 146).

Tip

Patients with a history of ischaemic heart disease, CVA/TIA, peripheral vascular disease or diabetics over 40 years should be started on a statin (e.g. simvastatin starting at 40 mg on) to achieve a total cholesterol <5.0 mmol/l or a 20–25% reduction, whichever is the lower value.

• Total cholesterol >10 mmol/l: refer to the lipid clinic.

Follow-up

• At 3-monthly intervals, initially.
• If the serum cholesterol level is reduced, reinforce dietary measures and concentrate on other risk factors for cardiovascular disease.
• Check LFTs at the first follow-up if a statin has been started.
• Titrate the dose of statin to achieve target cholesterol.
• Remember the coronary risk rises with age. Reassessment of risk level may indicate treatment at some point in the future. Plan to reassess the patient at a suitable interval.

INTERMITTENT CLAUDICATION

Intermittent claudication is often a sign of more widespread atheromatous disease, which should be sought.

Diagnosis

History.

Ask about pain in the legs on walking, which is relieved by rest. The calves are usually affected. Risk factors:

• smoking
• hypertension
• diabetes
• established atheromatous disease.

Examination.

This may be normal, but:

• look for cold feet, no hair on legs, dry or flaky skin
• check BP and peripheral pulses
• check the feet for corns, fungal infections, badly cut nails.

Investigations.

As for general atheromatous disease, i.e.:

• cholesterol
• fasting blood glucose
• ECG. Also consider Doppler pressures if available.

Management

• Document the distance at which claudication begins.
• Involve a podiatrist.
• Consider aspirin and statins (see p. 146).

Advice

• See general lifestyle advice (p. 146).
• Ask patient to report early signs of damage to the feet, e.g. blisters.

Referral.

If this general advice fails to help, refer to vascular surgical outpatients for consideration for angiography to assess the arterial supply to the legs.

CHEST PAIN

The causes of chest pain can range from minor musculoskeletal aches to life-threatening cardiac ischaemia. Surprisingly, both conditions are relatively common in general practice.

Diagnosis

History.

In diagnosing chest pain a good history is essential, especially if the initial contact is over the telephone.

The first question to ask yourself is, ‘Is it an emergency?’, i.e.:

• myocardial infarction
• dissecting aneurysm
• pulmonary embolus.

Ask about:

• The nature of the pain: central, crushing tight pain radiating to arms or neck suggests MI; central, tearing pain radiating to the back suggests dissection. PE causes pleuritic pain and often shortness of breath.
• The patient’s appearance: collapsed, pale or grey, breathless and sweaty all suggest serious pathology.
• Risk factors for MI and dissecting aneurysm: see risk factors for CVD (p. 146).
• Risk factors for PE:

– recent DVT
– surgery
– trauma
– combined pill
– smoking
– history of thrombosis
– long-haul flight (economy-class syndrome).

If the history suggests MI, aneurysm, PE or a very ill patient, admit the patient to hospital by ambulance on 999 without delay (see p. 158).

If the initial impression is of non-urgent pathology, a more leisurely history and examination can be performed.

The main differential diagnosis then includes:

• oesophagitis/reflux
• angina/MI
• costochondral/musculoskeletal pain
• chest infection/tracheitis.

A detailed account of the nature of the patient’s pain, including site, character, onset, duration, aggravating and relieving factors, associated symptoms and recent past medical history will usually provide a diagnosis.

Examination

• General appearance.
• Pulse.
• BP.
• Temperature.
• Chest, heart and abdomen. Do not forget to press on the chest wall to elicit musculoskeletal pain (common).
• Listen for the friction rub of pericarditis (rare).
• Epigastric tenderness suggests gastritis/reflux.

Investigations

• ECG: this may show evidence of acute MI or ischaemia, but may also be normal in both these conditions.
• CXR: this is of little diagnostic value, but it may confirm a chest infection, fractured rib or rib metastases.

If the patient is unwell or the history suggests an MI, immediate admission to hospital is essential.

Tip

The diagnosis often remains unclear at this stage. The confusion is usually between myocardial ischaemia and oesophagitis/reflux.

A therapeutic trial of either a PPI or a nitrate/beta-blocker is then justified, e.g.:

• omeprazole 20 mg od, or
• GTN sublingual prn or atenolol 100 mg od.

The choice is governed by the ‘best guess’ based on the history and examination so far.

Follow-up.

If the diagnosis is still in doubt after 24–48 hours on a therapeutic trial, referral to the cardiology outpatient clinic for the purpose of reaching a diagnosis can be justified. The following pages outline the management of ischaemic chest pain once a clinical diagnosis has been reached.

ANGINA

Angina is pain due to myocardial ischaemia.

Diagnosis

History.

Ask about:

• the nature of the pain: central, tight or constricting, radiating to the arms or neck
• aggravating factors: exertion, walking uphill or into the wind, cold weather, large meals
• relieving factors: rest, nitrates
• risk factors (see p. 146).

Examination.

Expect this to be normal. Look for:

• heart failure (ankles, lung bases and JVP)
• arrhythmias/murmurs.

Investigations.

• FBC: anaemia may unmask angina.
• ECG: a baseline ECG may be helpful for future reference, but expect this to be normal.
• CXR: this is unhelpful unless heart failure is suspected.

Tip

At this stage the diagnosis should fall into one of four groups:

• uncertain diagnosis (see p. 154)
• stable angina
• unstable angina
• suspected MI (see p. 158).

STABLE ANGINA

This is angina that is predictable, i.e. the symptoms are brought on by similar amounts of exercise every time; they are relieved by rest; and there is no change in the frequency of the attacks.

Management

Advice.

See general lifestyle advice (p. 146). Warn the patient to report any increase in chest pain immediately.

Prescribing

• Start with a trial of a moderately cardioselective beta-blocker, e.g. atenolol 50–100 mg od.
• A long-acting calcium-channel blocker can be added if symptoms persist, e.g. amlodipine 5–10 mg od.
• Sublingual nitrate tablets or spray should be made available to the patient for the temporary relief of angina, e.g. one or two GTN tablets prn. (Warn of headache.)
• Oral nitrates can be added if the patient requires a regular daily dose of the sublingual preparation, e.g. isosorbide mononitrate 10–20 mg tds.

All patients with angina should take aspirin 75 mg daily, unless contraindicated, and a statin (see p. 153).

Referral.

Refer for exercise ECG/angiography in all new cases of suspected angina via fast-track chest pain clinic (i.e. to be seen within 2 weeks).

Follow-up.

Continue lifestyle advice and attention to other risk factors.

UNSTABLE ANGINA

This is angina that has grown worse/more frequent over the previous month or less. Particularly worrying are rest pain and nocturnal pain.

Management

Discuss with the cardiology team with a view to an urgent outpatient appointment or admission.

Otherwise the management is as for stable angina.

Administration

Quality and Outcomes Framework for Coronary Heart Disease

• All new cases of angina to be confirmed by exercise test/specialist referral.
• Record smoking status annually.
• Offer smoking cessation advice to current smokers annually.
• Measure and achieve blood pressure 150/90 or below annually.
• Measure and achieve total cholesterol 5 mmol/l or below annually.
• Prescribe aspirin or clopidogrel or warfarin.
• Prescribe a beta-blocker.
• Give a flu jab annually.
• Screen for depression annually.

ACUTE MYOCARDIAL INFARCTION (MI)

This is a true general practice emergency, for which immediate action has been shown to reduce mortality. Among a GP’s 2000 patients there will be two episodes of acute MI per year.

Call 999 and request ambulance paramedics as soon as an acute MI is suspected, even if this is before the patient has been seen.

Diagnosis

History.

Ask about:

• the nature of the pain, e.g. central, crushing, tight chest pain radiating to arms or neck
• associated features, e.g. nausea, breathlessness, sweatiness, palpitations
• risk factors (see p. 146).

Examination.

The general appearance is usually of an anxious, slightly sweaty patient.

Check the blood pressure and pulse to assess for cardiac output and arrhythmias. Examine for signs of heart failure. The heart sounds are usually unchanged.

Investigations

• ECG: if an ECG machine (or a defibrillator with cardiac monitor) is available, it is worth connecting it up, but this must not delay the calling of the ambulance. If the diagnosis is in doubt, a normal ECG will not rule out an acute MI.
• Cardiographic monitoring is most useful in the acute situation for the detection and treatment of arrhythmias.

Tip

If the diagnosis is in doubt, see: chest pain, diagnosis (p. 154).

Immediate management of suspected MI

• Reassure the patient.
• Make sure the ambulance has been called.
• Site an intravenous cannula.
• Give pain relief intravenously, e.g. diamorphine 2.5–5 mg or morphine 5–10 mg (the dose being titrated against the patient’s response) with an antiemetic (e.g. prochlorperazine 12.5 mg iv or metoclopramide 10 mg iv).
• For heart failure give furosemide 40 mg iv.
• For hypotension (systolic pressure <100 mmHg) with bradycardia (<50) give atropine 300 μg iv. Repeat at 5-minute intervals to a maximum dose of 1.2 mg.
• Give aspirin 300 mg, unless contraindicated.
• Await the arrival of the ambulance and be prepared for the risk of cardiac arrest. Check the BP and cardiac rhythm regularly.
• Telephone the hospital to inform the medical team of the patient’s imminent arrival. If there is time before the ambulance departs, write a covering letter, listing the time of onset of symptoms, drugs given and cardiac history.

Late presentation of MI

• If less than 24 hours have elapsed, admit the patient.
• If more than 24 hours have elapsed since the onset of severe chest pain, it is not essential to admit the patient, as long as there are no remaining symptoms or signs.
• If the patient is kept at home, examine regularly for signs of heart failure. Confirm diagnosis by taking bloods for cardiac enzymes (troponin).

POSTMYOCARDIAL INFARCTION

The aim of primary care after an acute MI is to support the patient and family in rehabilitation and secondary prevention. Hospital outpatient care should include assessment of the need for coronary revascularisation and also cardiac rehabilitation.

Diagnosis

Examination.

Look for:

• arrhythmias, hypotension, murmurs, signs of heart failure
• the psychological effects of MI, which include

– depression
– beta-blocker side-effects
– fear of physical exertion
– insecurity
– pessimism.

Tip

Pay attention to risk factors (see also p. 146).

Management

(In conjunction with cardiac rehabilitation.)

Advice.

The patient should aim to return to normal activities by 6 weeks. This includes driving and sex. Graduated increase in the level of exercise should be limited by pain or tiredness. Regular daily exercise should be encouraged.

Prescribing.

Ensure that the patient is taking:

• aspirin 75–150 mg od (unless contraindicated)
• a beta-blocker (unless in heart block)
• a statin
• an ACE inhibitor.

Check the patient understands the importance of long-term compliance.

Administration

Quality and Outcomes Framework for Myocardial Infarction*

• Prescribe an ACE inhibitor

* In addition to the targets for CHD (see p. 158).

HEART FAILURE

Congestive cardiac failure is a clinical syndrome of shortness of breath, fatigue and fluid retention. It affects about 1–3% of the population.

Tip

Swelling of the ankles is a common general practice symptom. The commonest cause is dependent oedema due to venous insufficiency. Once heart failure has been excluded, treat with support stockings and elevate the legs. A mild diuretic such as bendroflumethiazide 2.5 mg od may be used if necessary.

Diagnosis

There are two aspects: diagnosing heart failure and diagnosing its cause.

History.

Ask about:

• symptoms of heart failure: shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, swollen ankles, fatigue
• possible causes of heart failure: past MI, past heart surgery, anaemia, thyrotoxicosis, arrhythmia, CHD, NSAIDs (fluid retention).

Examination.

Look for:

• signs of heart failure: raised jugular venous pulse, basal crackles, swollen ankles
• possible causes of heart failure: high output: anaemia (pallor), thyrotoxicosis (exophthalmos); low output: arrhythmia (irregular pulse, tachycardia), hypertensive disease (raised BP), valvular heart disease, e.g. aortic stenosis, mitral regurgitation (murmur)
• signs of associated cardiovascular disease: carotid bruits, absence of peripheral pulses.

Investigations.

Consider:

• Bloods: FBC: anaemia; TFTs: thyrotoxicosis; C&Es: prior to treatment; LFTs: can be disordered in heart failure.
• CXR: left ventricular hypertrophy/aneurysm, cardiomegaly.
• ECG: LVH, arrhythmia, tachycardia, MI.
• Echocardiogram (by referral) for all patients.

Management

Is the patient in acute left ventricular failure? If so, treat as an emergency:

• Give:

– diamorphine 2.5–5 mg iv
– furosemide 40 mg iv
– GTN sublingual
– O2 when available.

• Sit the patient up to decrease pulmonary oedema.
• Consider admission.

Treat the underlying cause specifically, if possible.

Advice.

See p. 146.

Prescribing

To control symptoms.

Diuretic, e.g. furosemide 20–40 mg mane.

To improve prognosis

• ACE inhibitor, e.g. lisinopril 2.5–20 mg od.
• Beta-blocker, e.g. carvedilol 1.25 mg od.

Method of starting ACE inhibition

• Check C&Es.
• Omit diuretics on the morning of initiating therapy.
• Increase the dose by a factor of 2 every week, if tolerated. Check C&Es at 2 weeks and BP with every dose increase.
• Avoid potassium-sparing diuretics and potassium supplements.

Follow-up

• Regular review, probably 6-monthly, but depends on the severity and underlying cause.
• Continued lifestyle advice and encouragement.
• Consider stopping treatment if the underlying cause is corrected.

Administration

Quality and Outcomes Framework for Heart Failure

• All cases of heart failure to be confirmed by echocardiography.
• Prescribe an ACE inhibitor or angiotensin receptor blocker.

RAYNAUD’S PHENOMENON

Raynaud’s phenomenon is characterised by cold, blue fingers after exposure to cold. It can be caused by vibration, e.g. driving, and can also affect the toes.

Management

• Reassure the patient it is not dangerous.
• Encourage the patient to stop smoking.
• Advise keeping the hands warm, using gloves if necessary.
• Nifedipine 10 mg tds can be used if the symptoms are severe. Increase to 20 mg tds if there is no response after 1 week.
• Surgery: sympathectomy may help severe disease.

Tip

Consider other connective tissue disorders, e.g. scleroderma, systemic sclerosis.

Tip

Treat any underlying disease which may be associated, e.g. peripheral vascular disease (see p. 153).

FUNNY TURNS

Syncope is characterised by transient loss of consciousness, with or without a fall. Simple vasovagal faints are the commonest cause of syncope in young patients. The phrase ‘funny turn’ is often used by patients and relations to describe a wide variety of symptoms, which include syncope (see dizziness, p. 274).

The causes can be divided as follows.

Non-pathological

• Faints
• cough/micturition syncope.

Cardiovascular

• Arrhythmia
• valvular
• postural hypotension
• vertebrobasilar insufficiency.

Neurological

• TIA/CVA
• epilepsy.

Other

• Hypoglycaemia.

Diagnosis

History.

Ask about:

• Preceding symptoms:

– palpitations (arrhythmia)
– aura (epilepsy)
– emotional stress (faint)
– cough/micturition (syncope)
– chest pain (ischaemia).

• Witnessed account:

– tonic/clonic
– tongue-biting
– asymmetrical weakness
– urinary incontinence (epilepsy)
– postictal drowsiness.

• Drug history (for postural hypotension): diuretics, nitrates, tricyclics, antihypertensives, sedatives, hypnotics, neuroleptics.
• Family history of sudden death: cardiomyopathy.

Examination.

Look for:

• Cardiovascular:

– pulse (irregular)
– BP (postural drop)
– heart sounds (aortic stenosis)
– carotids (bruits)
– extend neck (causes faintness in vertebrobasilar insufficiency).

• Central nervous system:

– postictal
– residual CVA/TIA deficit.

Investigations

• FBC.
• C&Es (if on digoxin/diuretics).
• Blood glucose.
• ECG.

Management

Treatment.

The following are treatable in general practice:

• Postural hypotension:

– advise the patient to rise slowly
– surgical stockings
– change responsible drugs if possible.

• Some arrhythmias (see below).
• Vertebrobasilar insufficiency:

– explain the symptoms
– advise the patient to avoid sudden neck movements.

• TIAs:

– Rx (as per p. 281)
– identify cause (e.g. AF).

• Hypoglycaemia:

– if known diabetic: glucose orally or iv (50 ml of 50% solution)
– may need to adjust daily insulin dose.

Referral

• TIA: to Stroke Clinic preferably.
• Some arrhythmias (see below).
• Valvular heart disease.
• New or poorly controlled epilepsy.
• Unexplained loss of consciousness. (Refer to either a cardiologist or a neurologist.)

Recurrent syncope

• Is the diagnosis correct?
• Advise the patient to avoid dangerous situations.
• The patient should inform the Driver and Vehicle Licensing Agency.

PALPITATIONS

Palpitations are an awareness of the heart beating due to either a change of beat or a heightened awareness of the normal cardiac rate and rhythm.

Tip

There are various ways of subdividing arrhythmias, but the most useful in general practice is the distinction between normal and pathological.

Normal (common)

• Increased awareness of the normal heart beat.
• Tachycardia: anxiety feedback loop.
• Menopausal flushing.
• Ventricular ectopics.

Pathological

• Paroxysmal supraventricular tachycardia.
• Atrial fibrillation

– constant
– paroxysmal.

• Second- and third-degree heart block.
• Ventricular tachycardia.

Diagnosis

History.

Ask about:

• Rate and rhythm. (Ask patient to tap on the desk.)
• When the palpitations occur.
• Associated symptoms:

– faintness/dizziness
– loss of consciousness (see p. 163)
– anxiety
– tingling of the fingers or perioral area (hyperventilation)
– hot flushes/sweats
– shortness of breath.

• Exacerbating factors.
• Drug history.
• Cardiovascular history.

Examination

• Anaemia.
• Pulse, BP.
• Thyrotoxic?
• Heart sounds.
• Apex–radial delay (atrial fibrillation).

During attack

• Pulse, BP.
• Signs of heart failure (see p. 161).
• ?MI (see p. 158).

Investigations

• Bloods:

– FBC
– C&Es
– TFTs
– digoxin level.

• ECG:

– routine
– during attack.

(A 24-hour ECG is usually by referral.)

Management

Treatment.

The following are treatable in general practice.

Non-pathological arrhythmias.

Reassure (backed up by ECG).

Constant atrial fibrillation.

If ventricular rate is >100 per minute and there is no murmur, give digoxin 0.25 mg po, then 0.25 mg 12 hours later, and then 0.125 mg daily for 1 week if C&Es are normal. Then assess ventricular rate and adjust dose accordingly.

Anticoagulate with warfarin, over the age of 50, unless there are contraindications, in which case give aspirin, 75 mg daily (see p. 330).

Paroxysmal atrial fibrillation.

Anticoagulate if there are no contraindications; otherwise give aspirin. Digoxin is of no benefit.

Symptomatic supraventricular tachycardia.

Advise the dive reflex (plunge the face into a sink of cold water)/Valsalva manoeuvre/carotid sinus massage. Stop stimulant intake (coffee, tea, chocolate, cola, etc.).

Emergency treatment of arrhythmias following acute myocardial infarction includes:

• ventricular tachycardia: lidocaine 100 mg iv
• sinus bradycardia: atropine 300 μg iv
• ventricular ectopics: no treatment
• ventricular fibrillation: DC shock
• asystole: 1:1000 adrenaline 1 ml iv and CPR.

Referral.

Refer if there is:

• no diagnosis (if symptoms are worrying patient or doctor)
• atrial fibrillation of recent onset (for DC cardioversion)
• atrial flutter
• paroxysmal ventricular tachycardia
• heart block
• associated valvular heart disease
• thyrotoxicosis
• SVT not responding to above advice.

Administration

Quality and Outcomes Framework for Atrial Fibrillation:

• All new cases to be confirmed by ECG.
• Anticoagulate all cases of AF unless warfarin contraindicated.

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