Chest pain and discomfort are common symptoms that account for 1% of visits to primary care, 5% of visits to accident and emergency departments and 25% of emergency hospital admissions. Coronary artery disease (CAD) is one of many causes of chest pain and is the commonest cause of death in the UK. However, there are treatments available that can improve symptoms and prolong life, making prompt assessment and diagnosis essential. The National Institute for Health and Clinical Excellence (NICE) has recently published a new guideline on the assessment and investigation of patients presenting with acute chest pain suggestive of acute coronary syndrome (ACS) and stable chest pain suggestive of angina. It includes recommendations that will mean some changes to the way these patients are managed in practice. This article looks at how we can put these changes into action.
How to use the GRASP-AF tool to reduce stroke risk in patients
Eating healthily on a tight budget
Save the Children, a charity well known for its work helping children in war-torn or faminestruck countries, recently announced that it is now handing out grants to struggling UK families who cannot afford to feed themselves. In a recent report, the charity suggests that the credit crunch has led to an increase of 11.3% in cost of food over the last year. It is not surprising that many parents have now cut back on food expenditure, with the poorest of families spending less on their weekly shop than ever before. How can we provide patients with tips on eating healthily on a tight budget?
Treating erectile dysfunction safely and effectively
Erectile dysfunction (ED) and vascular disease share the same risk factors and commonly co-exist. The presence of ED in otherwise asymptomatic men is, therefore, often a useful early warning sign of silent vascular disease. This fundamental concept highlights the importance of ‘looking beyond the penis’ in the evaluation of the ED patient, and challenges practice nurses to consider ED and sexual activity as part of their routine evaluation of patients. Once diagnosed, there is a range of effective treatments for ED, and guidance on how to use them safely in patients with cardiovascular disease (CVD).
Managing chronic obstructive pulmonary disease and cardiovascular disease together
Chronic clinical conditions have traditionally been regarded as individual disease categories within individual patients, although there is often considerable overlap across clinical systems. The monitoring of patients with long-term conditions has historically centred around a traditional model of a nurse-led clinic, utilising an appropriate level of skill mix. The disease categories and associated clinical indicators of the Quality and Outcomes Framework (QOF) have encouraged this approach, but for those managing these patients the presence of various co-morbidities is all too apparent
Effective management of atrial fibrillation
Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia, and has a significant impact on morbidity and mortality. Treatment is tailored to the individual. This article will review the rhythm-management strategies for patients with atrial fibrillation, and discuss the roles of secondary and tertiary care.
Management and early treatment of transient ischaemic attack (TIA)
The White Paper, Saving lives: our healthier nation (1999), set out a target to reduce the death rate from coronary heart disease and related illnesses such as stroke by 40% in the under-75s by 2010;1 recent trends indicate that this target will be met. Although the past forty years have seen a significant reduction in age-standardised stroke mortality rates, stroke still accounts for around 53,000 deaths each year in the UK, with more than 9,500 of these occurring in the under-75s.2 This article reviews how we might reduce the huge burden of stroke by improving the management of transient ischaemic attack (TIA).
What is the real role of anticoagulants in atrial fibrillation and stroke?
The majority (84%) of people with AF are over the age of 65 years. In the UK, the prevalence of AF is 7.2% for patients aged 65 and over. AF is a particularly important risk factor for stroke in the elderly. 15% of all strokes are associated with the arrhythmia, increasing to 36% in people over the age of 80. The prevalence of AF is higher in men at all ages, although the overall number of patients with AF is approximately equal between the sexes because of unequal death rates. In overall terms, approximately 50% of patients with AF are 75 or over, and over half of these are women.
Catheter and surgical ablation of cardiac arrhythmias
Catheter and surgical ablation of cardiac arrhythmias have evolved rapidly over the last 30 years. Catheter ablation of ‘simple’ atrial arrhythmias such as supraventricular tachycardias and typical atrial flutter is very successful and low-risk. Catheter ablation of atrial fibrillation (AF) is now also successful in restoring sinus rhythm for the majority of patients. The place of invasive treatment for ventricular arrhythmias in various contexts is also evolving.
Following implementation of the Department of Health’s Chapter 8 of the National Service Framework in 2005, there has been expansion of arrhythmia services in the UK. In 2010, the capacity of hospitals to treat these arrhythmias is growing rapidly, and perhaps the main barrier to patient access is the limited awareness among would-be referring physicians of which patients should be referred for such treatments. This review article outlines the ways in which arrhythmias can be treated by catheter and surgical ablation, and provides success and complication rates to help the reader determine when, and for whom, these treatments might be appropriate.
Risk stratification for stroke in patients with non-valvular atrial fibrillation – can we improve decision-making for optimal treatment?
Antiplatelet (usually aspirin) and anticoagulant (usually warfarin) treatments are available to reduce the risk of stroke in patients with atrial fibrillation (AF) but both have potentially harmful adverse effects and warfarin can be time-consuming and expensive to monitor. Guidance exists for choosing between treatments but is often insufficiently detailed to support an informed choice about the risk and benefits. Prescribers and patients are often left with a choice between aspirin or warfarin, and aspirin – which is perceived to be safer and easy to use – is often chosen. This article explores the evidence for aspirin and warfarin in preventing stroke in patients with AF, and describes how we should change the way that decisions about treatment are made.
Atrial fibrillation: a significant risk factor for stroke
Atrial fibrillation (AF) is the commonest sustained arrhythmia, affecting 1.2% of the population, which equates to more than 600,000 people in England. The prevalence of AF increases with age, with 8.4% of the over-65 age-group affected and also it is increasing in incidence and prevalence.Each year there are 150,000 strokes in the UK. Nearly one in five (18%) of the people presenting with a stroke are in AF at the time of presentation, and one in six strokes are directly attributable to AF.
EDITORIAL | Keeping up with two professions: medicine and literature
Like Chekhov, doctors have to find time for both medicine and literature – in our case, the latest research literature. Finding time to read all that is necessary to keep up-to-date is a real challenge for most GPs, especially those with a special interest in cardiology or diabetes, but helps by summarising the most important developments.
