Managing heart failure requires a holistic approach: as well as optimal medical treatment, patients and their families need to have a sufficient understanding of the condition. There also needs to be a service to deliver this care. Heart failure affects about 0.5% of the population, depending on the age of the population, so each general practice has a manageable number of patients. However, the expertise and confidence needed to deliver optimal care to heart failure patients and their families are not widely held in primary care. There is largely a reliance on secondary care to provide community services, led by consultants and delivered by specialist nurses. Within this system patients are usually well served, but sometimes patients fall between the community service and general practice. In Central Manchester there is no community heart failure service. About one in five patients with heart failure were being admitted each year, indicating that heart failure management in the community needed to improve.
The new oral anticoagulants, and their use in stroke prevention
We have three new licensed anticoagulant agents–dabigatran, rivaroxaban and apixaban. Their use for stroke prevention in AF is discussed: primary care is central to their utilisation.
Keeping the blood flowing: new agents to prevent and treat thrombosis
We live in exciting times with the development of several new oral anticoagulant agents, including the recent approval of the direct thrombin inhibitor dabigatran for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF). Dabigatran, an oral agent with fixed dosing, is an attractive alternative to warfarin which has recently been made available in the UK. What are the implications for UK primary care? Many patients with AF receive substandard anticoagulation and are therefore at risk of stroke. Evidence for its efficacy and its potential place in clinical practice is reviewed.
Introducing the new national strategy for CVD
As many will know, the Secretary of State for Health, Andrew Lansley, announced last December that the government would be developing a new strategy for cardiovascular disease under the direction of Sir Bruce Keogh (NHS Medical Director). As part of this work two Interim National Clinical Directors have been seconded to the Department of Health: me (Professor Huon Gray, University Hospital of Southampton) for Cardiovascular Disease and Dr Damian Jenkinson (Royal Bournemouth Hospital) for Stroke. Both are part-time secondments and together cover the work previously overseen by Professor Sir Roger Boyle, before his retirement last summer.
Heart rate control in people with heart failure: education may improve outcomes
There is emerging evidence that heart rate control is an important element in the management of people with heart failure. The major beta-blocker trials have shown improved mortality and reduced hospitalisation when patients with impaired left ventricular (LV) function are managed with optimal doses. In a meta-analysis of these trials, McAlister et al. have shown a correlation between heart rate control and improved outcomes.1 Beta-blockers may have other actions apart from heart rate control; for instance, they may be anti-arrhythmic or have some other mechanisms for their action. Ivabradine, whose only function is heart rate control, has also shown a reduction in hospitalisation for heart failure.2 Heart rate is additionally an indicator of optimal beta-blockade3, and so may be a proxy for optimal medical treatment.
Recognising stroke and transient ischaemic attack – the role of primary care
Stroke is the third commonest cause of adult death and the leading cause of complex disability in the UK. This article will discuss the importance of the early recognition of stroke and transient ischaemic attack and the role of primary care staff in implementing national guidelines. Practical case study examples are included.
Vitamin D and cardiovascular health
Vitamin D deficiency is a prevalent and important health issue that warrants vigilant systematic screening and appropriate treatment and follow-up on the part of physicians, especially those in the primary care and cardiovascular fields. Although vitamin D deficiency has traditionally been associated primarily with bone disease, it is now clear that this is a multi-organ system disease. Epidemiological studies consistently show strong associations between vitamin D deficiency and bone disease, cancer and diabetes. Additionally, epidemiological evidence links vitamin D deficiency with cardiovascular risk factors, cardiovascular disease and mortality. Conclusive evidence to show that vitamin D supplementation improves cardiovascular prognosis is currently lacking, although randomised trials are under way to address this issue. In this article we review the sources and metabolism of vitamin D, the epidemiology of vitamin D deficiency, and the available evidence linking vitamin D deficiency to cardiovascular disease; and we suggest an approach to systematic screening and to treatment of vitamin D deficiency.
Understanding the impact of statin titration: a modelling approach
Introduction: Clinical guidelines specifying target cholesterol levels may require dose titration strategies for patients who do not reach target. We describe a model that simulates cholesterol and cardiovascular risk reductions for different populations, therapies, titration steps and targets.
Looking back, looking forward: reflecting on the winter season and the demise of the PCCS
The message regarding eating less has come across loud and clear this year, but there has been plenty to worry about over the last twelve months. The demise of the Primary Care Cardiovascular Society (PCCS) has been on my mind. I was saddened to attend an Extraordinary General Meeting in January 2012, when it was decided to wind up the Society with honour due to declining funds and concern that this situation was likely to deteriorate for the foreseeable future. The closure of the PCCS is a great blow to all of us interested in promoting and improving the prevention and management of cardiovascular disease in our communities.
Atrial fibrillation and stroke: Optimising prevention and treatment
Uniquely, AF is an eminently preventable cause of stroke with a simple and highly effective treatment. AF is common and affects over 600,000 patients in England (1.2%). It is a major predisposing factor for stroke, and strokes caused by AF can be particularly severe and disabling. The annual risk of stroke is five to six times greater in AF patients, but […]
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).
