Cardiovascular

Reducing hospital admissions for patients with heart failure: the impact of a Local Enhanced Service

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.

Broken heart syndrome (Takotsubo cardiomyopathy)

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.

Cardiovascular drugs and sexual dysfunction

Men and women with cardiovascular disease are currently treated with multiple medicationsto reduce their cardiovascular risk. Although the links between erectile dysfunction (ED) andcoronary heart disease (CHD) are well established and ED often precedes the onset of CHD by3-5 years, few men in UK general practice are asked about their erections prior tocommencement of therapy for cardiovascular disease. The presumption is often that if thepatient has a sexual problem, then he will mention it and at that point the therapy can bechanged. There are two drawbacks with this approach: first, men do not readily volunteersexual problems, and second, unless the therapy change is made quickly, the problem isunlikely to resolve.5 Physicians must be aware that in many cases, such as the use of betablockersafter acute myocardial infarction, the appropriate management of the cardiaccondition is the major priority.

Choosing the NTproBNP cut off for use as part of a community heart failure care pathway

Echocardiography (ECHO) is the “gold standard” test in the diagnosis of heart failure. Brain natriuretic peptide (BNP) can be helpful to rule outpatients who do not require ECHO. This study used an elevated level of Nterminal prohormone BNP (NT-proBNP) as a criterion for referral to a new community heart failure clinic. Results showed that NT-proBNP could be a useful test in the management of heart failure. The researchers propose to institute age- and sex-related cut-offs to refine its place in the patient care pathway.

Working long days increases CVD risk, but constant new challenges keep dullness at bay

Although many members of the medical profession might agree that theirchosen discipline often leads to periods of weariness, frustration or anxiety, thegreat majority of individuals in active practice would find it difficult to single outa dull day in their way of life.” (David Seegal, Yale Scientific Magazine 1962;36:31)

Screening for peripheral arterial disease: a real chance to improve patient care

Symptomatic peripheral arterial disease (PAD) affects 3-5% of the population over 60 years of age. Many patients with PAD are unaware of their diagnosis, and hence may not have mentionedthe classical symptoms to their GP. The Edinburgh questionnaire is a validated tool thathelps identify susceptible patients. The questionnaire was administered to patients routinelyattending annual influenza immunisation clinics, in order to identify patients potentially at risk ofPAD. In all, 2.9% of the >65yr cohort were identified by the questionnaire as at risk of PAD.Opportunity was made for these patients to have their risk factors reviewed, and managementwas adjusted in line with the Target PAD algorithm. Reducing the risk factor profile of suchpatients improves quality of life scores, morbidity, and mortality. Periodic screening of an ‘atrisk’population may identify individuals who would gain considerable benefit from furtherevidence-based management.

The EPCCS and the implementation of CVD prevention in general practice

The European Primary Care Cardiovascular Society (EPCCS) exists to inform, support and interact with general practitioners (GPs) across Europe in relation to cardiovascular disease, including stroke and diabetes. The EPCCS provides an interactive and expanding website at www.epccs.eu with news, comments, information, meeting reports and slide presentations.

A local strategy to improve outcomes for TIA and stroke

We describe here a project that sets out to reduce the risk of stroke in patients suspected of having a transient ischaemic attack.

Out of the shadows: attitudes and beliefs of primary care practitioners about depression after myocardial infarction

After myocardial infarction (MI) half of all patients will experience an episode of depression. We carried out the first survey of GP and primary care nurse attitudes and beliefs about depression in post-MI patients. Our sample was drawn from readers of two major cardiovascular journals: a total of 813 GPs and nurses responded. Primary care practitioners underestimated the prevalence of depression which is two and a half times more common in post-MI patients than estimated. Diagnosing depression was viewed as complex by both groups but much more so by nurses. Compared to nurses GPs had a much better understanding of the signs and symptoms of depression and were more confident in using depression screening tools. General acknowledgement of the negative impact that depression can have on outcomes was reported by the majority of participants. The practice of depression-trained professionals was more positive compared with those who had no recent education. If primary care practitioners address the epidemic of depression in post-MI patients, outcomes will be dramatically improved and lives could be saved.

“Time is brain” – thrombolysis in acute stroke

“Time is brain” – thrombolysis in acute stroke – Mark Garside, Christopher PriceStroke is a common condition with long-term consequences. If symptoms are recognised early enough and patients are transported rapidly to hospital then there is the opportunity to administer treatments which may reduce long-term disability. We summarise the role of intravenous thrombolysis in the treatment of acute ischaemic stroke, including supporting evidence, how it is used in clinical practice, and possible future developments.

Once-weekly exenatide: a new therapeutic option for glucose lowering

The evidence for, and usefulness of, once-weekly exenatide (Bydureon) are discussed in this review. It may be initiated in primary care since it has effects on glucose lowering and global cardiometabolic risk

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