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.

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