🫀 CARDIOVASCULAR MEDICINE for GPs: Your Survival Guide

Updated Guidelines 2024:

NICE CG181 updated lipid modification guidelines, new QRISK3 calculator integration, and revised hypertension thresholds (NICE NG136). ESC/EAS 2023 dyslipidaemia guidelines now emphasize personalized risk assessment.

🫀 CARDIOVASCULAR MEDICINE for GPs: Your Survival Guide

Heart-stopping knowledge without the actual heart stopping - your cardiac confidence booster!

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚨 Red Flag Focused

Date Updated: November 2025

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

What This Page Covers:

• Red flags & life-threatening presentations
• Diagnostic frameworks & risk calculators
• Common conditions management
• Prevention strategies & health promotion
• Referral pathways & follow-up guidance
• MRCGP exam preparation tips

Quick Facts at a Glance:

15%

of MI patients die before reaching hospital

10%

die in hospital after MI

1-5%

serious arrhythmia in non-exertional palpitations

15%

serious arrhythmia in exercise-related palpitations

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Key Questions for Data Gathering

Chest pain: "Tell me about the pain - where, when, what brings it on, what makes it better?"

Breathlessness: "How many stairs can you climb before getting breathless?"

Palpitations: "Can you tap out the rhythm? Is it regular or irregular?"

Family history: "Any heart problems in family under 60 (men) or 65 (women)?"

Red Flags – What Not to Miss!

Chest pain + sweating/nausea/SOB = ACS until proven otherwise

Tearing chest/back pain = think aortic dissection

Syncope + murmur = urgent cardiology referral

Fever + new murmur = endocarditis until proven otherwise

SOB or feeling unwell in elderly = may be only feature of atypical MI

Exercise-related palpitations = serious until proven otherwise (15% have serious arrhythmia)

Remember: "Palpitations at rest are usually benign. Palpitations during exercise are never benign until proven otherwise."

Life-Threatening Cardiovascular Presentations

👉 Every GP should recognise and act on these immediately

Classic presentation: Central crushing chest pain, radiating to arm/jaw, with sweating, nausea, SOB

Atypical presentations: Especially in women, elderly, diabetics - may present as SOB, fatigue, epigastric pain

Action: 999 ambulance, aspirin 300mg (unless contraindicated), GTN if available, continuous monitoring

Classic: Sudden onset severe 'tearing' chest/back pain, may migrate

Examine: BP difference >20mmHg between arms, pulse deficits, new murmur

Action: Immediate 999 call, avoid thrombolysis, urgent CT angiogram

Massive PE: Collapse, severe SOB, chest pain, haemodynamic compromise

Risk factors: Recent surgery, immobility, cancer, pregnancy, previous VTE

Wells score: Use to guide investigation - if high probability, treat while investigating

VT/VF: Broad complex tachycardia >150bpm, may be pulseless

Complete heart block: Bradycardia <40bpm with symptoms

Action: If pulseless - CPR + defibrillation. If pulse present - urgent cardiology

🩺 Frameworks to Structure Cardiovascular Assessment

Stepwise Approach to Key Symptoms

Chest Pain (SOCRATES)

Site: Central, left-sided, radiating?
Onset: Sudden, gradual, time of day?
Character: Crushing, sharp, burning?
Radiation: Arm, jaw, back?
Associated: SOB, sweating, nausea?
Timing: Duration, frequency?
Exacerbating: Exercise, emotion, cold?
Severity: 1-10 scale

Breathlessness Assessment

• NYHA class (stairs climbed)
• Orthopnoea (pillows needed)
• Paroxysmal nocturnal dyspnoea
• Exercise tolerance changes
• Associated chest pain/palpitations
• Ankle swelling progression

Focused Cardiovascular Examination

General Inspection

Pallor, cyanosis, clubbing, breathlessness at rest, peripheral oedema, JVP elevation

Pulse & BP Assessment

• Rate, rhythm, character, volume
• BP in both arms (>20mmHg difference = concern)
• Peripheral pulses (radial, carotid, femoral)
• Radio-femoral delay

Precordial Examination

• Apex beat location and character
• Heaves, thrills, palpable sounds
• Heart sounds (S1, S2, added sounds)
• Murmurs (timing, location, radiation)

When and How to Use Risk Calculators

QRISK3

• Primary prevention CVD risk
• Age 25-84 years
• 10-year risk ≥10% = consider statin
• Includes ethnicity, deprivation

CHA₂DS₂-VASc

• AF stroke risk assessment
• Score ≥2 (men) or ≥3 (women)
• Consider anticoagulation
• Annual review required

HAS-BLED

• Bleeding risk with anticoagulation
• Score ≥3 = high bleeding risk
• Don't use to exclude anticoagulation
• Address modifiable factors

Appropriate Use of Investigations

ECG Indications

Chest pain, palpitations, SOB, syncope, new murmur, hypertension diagnosis, pre-op assessment

BNP/NT-proBNP

Heart failure suspected: BNP >100pg/ml or NT-proBNP >300pg/ml warrants echo within 6 weeks

Troponin

ACS suspected: High-sensitivity troponin at presentation and 3 hours. Interpret with clinical context.

Recognising When to Refer Urgently

Same day referral: Suspected ACS, aortic dissection, massive PE, symptomatic severe AS, complete heart block

2-week referral: Suspected heart failure with BNP >2000pg/ml, new murmur with symptoms

Routine referral: Heart failure with BNP 100-2000pg/ml, stable angina, AF for rhythm control consideration

Interpreting Secondary Care Results

Echo Reports

• LVEF >50% = normal
• LVEF 40-49% = mild impairment
• LVEF <40% = moderate-severe
• Valve gradients and areas
• Diastolic function assessment

Angiography Results

• % stenosis significance
• Vessel territories (LAD, RCA, LCx)
• Stent types and implications
• CABG vs PCI decisions
• Follow-up requirements

🧩 Symptom-Based Lists to Compare and Contrast Causes

Chest Pain Differential Diagnosis

Cardiac Causes

• ACS/MI - crushing, radiating, with autonomic symptoms
• Stable angina - predictable, exercise-related, relieved by rest/GTN
• Pericarditis - sharp, positional, worse lying flat
• Aortic dissection - tearing, sudden onset, migrating

Respiratory Causes

• PE - pleuritic, with SOB, risk factors
• Pneumothorax - sudden, sharp, unilateral
• Pneumonia - with fever, productive cough

Non-Cardiac Causes

• MSK - reproducible with movement, tender to palpation
• GORD - burning, worse after meals, lying down
• Anxiety - associated with panic symptoms
• Costochondritis - tender costal cartilages

Red Flag Features

• Sudden onset severe pain
• Radiation to arms/jaw
• Associated sweating/nausea
• Haemodynamic compromise

💡 Conditions GPs Must Diagnose, Manage, and Monitor Confidently

Hypertension & Cardiovascular Risk Management

NICE NG136 Diagnostic Criteria

• Clinic BP ≥140/90mmHg on 2+ occasions
• ABPM/HBPM average ≥135/85mmHg
• Measure BP in both arms (use higher reading)
• Consider white coat hypertension

When to Offer ABPM/HBPM

All patients with clinic BP 140-180/90-120mmHg to confirm diagnosis before starting treatment

Stage 1

Clinic: 140-159/90-99mmHg

ABPM: 135-149/85-94mmHg

Stage 2

Clinic: 160-179/100-119mmHg

ABPM: ≥150/95mmHg

Stage 3 (Severe)

Clinic: ≥180/120mmHg

Same-day assessment needed

Treatment Thresholds

• Stage 1: Treat if <80 years + CVD risk ≥10% or target organ damage
• Stage 2: Treat all patients regardless of age
• Stage 3: Immediate treatment + same-day specialist advice

First-Line Treatment (NICE 2024)

• <55 years: ACE inhibitor (or ARB if cough)
• ≥55 years or Afro-Caribbean: Calcium channel blocker
• Step 2: ACE-I + CCB
• Step 3: ACE-I + CCB + thiazide-like diuretic

Follow-up Schedule

• Monthly until target achieved
• Then 3-6 monthly when stable
• Annual review minimum
• Check U&E 2 weeks after ACE-I/ARB initiation

Target BP

Clinic: <140/90mmHg (or <150/90 if ≥80 years)

ABPM/HBPM: <135/85mmHg

🩺 Essential Hypertension Management Guide

NICE NG136 Definitions

• Stage 1: Clinic 140-159/90-99mmHg, ABPM/HBPM 135-149/85-94mmHg
• Stage 2: Clinic 160-179/100-119mmHg, ABPM/HBPM ≥150/95mmHg
• Stage 3: Clinic ≥180/120mmHg (severe hypertension)

BP Targets

• <130/80 if patient has other Chronic Disease (CVD/DM/CKD/TIA/CVA/PVD)
• <140/90 if only hypertension
• <150/90 if over 80 years for all conditions

Proper BP Measurement Technique

• Patient seated, arm supported at heart level
• Appropriate cuff size (bladder encircles ≥80% of arm)
• 5 minutes rest before measurement
• Measure in both arms (use higher reading)
• Take 2 measurements, 1 minute apart

White Coat Hypertension

Definition: Clinic BP ≥140/90mmHg but ABPM/HBPM <135/85mmHg

• More common in elderly, women, non-smokers
• Annual BP monitoring recommended
• Consider CVD risk assessment
• No antihypertensive treatment needed

Clinically Significant White-Coat Effect

Office or clinic blood pressure exceeding the daytime ABPM by 20 mmHg systolic or 10 mmHg diastolic either in the absence or presence of antihypertensive drug treatment

SEVERE HYPERTENSION: BP >180/120

What you do next depends on symptoms & examination signs indicating target organ damage

IF NO SYMPTOMS & NO EXAMINATION SIGNS

Before you do anything:

• Do an ECG & ACR (for end organ damage signs like LVH, ST changes, dysrhythmia)

If any signs of end organ damage:

1. Start standard antihypertensive Rx (like Amlodipine)
2. Get them to do ABPM/HBPM
3. Review within 7 days

If no signs of end organ damage:

• No need to start treatment
1. Arrange ABPM/HBPM
2. Review within 7 days – then decide on Rx
• ABPM/HBPM will help exclude white coat hypertension

IF SYMPTOMS AND/OR TARGET ORGAN DAMAGE SIGNS

ADMIT TO HOSPITAL SAME DAY

Target Organ Damage Symptoms:

• Chest pain
• Headaches
• Fits, funny turns

Target Organ Damage Signs:

• Retinal haemorrhage
• Papilloedema
• Confusion
• Heart failure signs
• Proteinuria

Also refer same day if you suspect PHAEOCHROMOCYTOMA:

• Labile/postural hypotension
• Headache, palpitations, pallor
• Abdominal pain
• Diaphoresis (excessive sweating for no apparent reason)

MALIGNANT (ACCELERATED) HYPERTENSION: BP >220/120

ADMIT TO HOSPITAL – STRICT BED REST

DO NOT add any antihypertensives because you do not want to reduce blood pressure too rapidly because of possible cerebral infarction – instead let the hospital do it. Hospital will aim to reduce the blood pressure to 110 mmHg diastolic over 24 hours.

Symptoms (remember: eyes-brains-lungs):

• Visual disturbance (eyes)
• Headache (brain)
• Hypertensive encephalopathy – blunting of conscious level, confusion, coma, epileptic seizures (brain)
• Breathlessness (lungs)

Examination Signs:

• Acutely high BP with diastolic >220/120 mmHg
• EYES: Fundoscopy – hypertensive retinopathy with haemorrhages and exudates; papilloedema from cerebral oedema
• KIDNEYS: Test urine – renal failure – dipstick for proteinuria
• HEART: Assess for cardiac failure – SOB, bibasal creps, worsening ankle oedema
• Rarely: haemoglobinuria, jaundice, anaemia (microangiopathic haemolytic anaemia)

NICE Treatment Algorithm

• Step 1: <55 years: ACE-I/ARB; ≥55 years: CCB
• Step 2: ACE-I/ARB + CCB
• Step 3: ACE-I/ARB + CCB + thiazide-like diuretic
• Step 4: Add spironolactone or alpha/beta-blocker
• Review at 4-6 weeks after each change

COMORBIDITIES - WHICH HTN RX ARE BETTER?

Options: A – ACEi or ARB; B – beta blocker; C – calcium channel blocker; D – thiazide like diuretic

CKD (Chronic Kidney Disease)

No diabetes:

• ACR <30 – use Standard guidance
• ACR >30 – offer A (ACEi/ARB)

With diabetes:

• ACR >3 – offer A (ACEi/ARB)

All patients with ACR >70: offer A (ACEi/ARB)

Diuretics will be key second line drugs:

• eGFR >30, use D (higher doses or bd)
• eGFR <30, use loop diuretics (higher doses or bd)

Caution with spironolactone in CKD. Start low dose, check U&Es a week later or a week after dose adjustment and consider monitoring every 3 months.

Chronic Heart Failure

• Patients should already be on A (ACEi/ARB) and B (beta-blocker)

• If BP remain poorly controlled, add D (unless already on loop diuretic)

• If control remains poor on A+B+D, get specialist advice on adding spironolactone or eplerenone

• For B, first line bisoprolol

Spironolactone monitoring as above

Type 2 Diabetes

Non-black patients:

• Start with A (ACEi/ARB) and add D and C as 2nd and 3rd line

Black patients:

• 1st line: A+D or A+C
• 2nd line: A+C+D

If triple therapy fails, consider α-blocker, B or spironolactone.

In women of child bearing age, C is first line (nifedipine in pregnancy)

Note: Aim is to get BP down. A (ACEi/ARB) are not superior to other hypertensives at reducing renal and cardiovascular endpoints. Most patients need combination therapy.

Type 1 Diabetes

• A (ACEi/ARB) is first line

• D or C as second line choices

Atrial Fibrillation

• If HR needs to be controlled consider adding either a β-blocker or a rate limiting CCB (e.g. diltiazem) to any existing therapy

• If already taking amlodipine, consider changing to a rate limiting CCB e.g diltiazem

The Term African Caribbean

The Afro-caribbean term is now replaced by African Caribbean (one r, two b's). African Caribbeans are persons of African descent born or living in a Caribbean nation. The Caribbean nations are those islands in North America which includes Jamaica and the Bahamas.

SPECIAL CASE: AFRICAN CARIBBEANS

For African Caribbeans <age 55:

Follow the standard anti-hypertensive Rx pathway:

• 1st-line: use Amlodipine (or thiazide if not tolerated)
• 2nd-line: Add ACEI (Ramipril) or ARB (Losartan or Candesartan)
• 3rd-line: Add thiazide

For African Caribbeans >age 55:

• 1st-line: use Amlodipine (or thiazide if not tolerated)
• 2nd-line: Add ARB like Losartan or Candesartan (not ACEI)

For African Caribbeans + any age + HTN + diabetes:

• 1st-line: ACEI like Ramipril
• 2nd-line: Stop ACEI, replace with ARB like Losartan or Candesartan

Why ARB instead of ACEI?

I tried to look this up on the internet and it was difficult to find the answer. SO the following is based on my supposition, going back to our biochemistry medical student days… If you know the correct answer, please let me know rameshmehay@googlemail.com

Blood pressure is reduced because ACE inhibitors block an enzyme early in the system, resulting in lower production of angiotensin, which can narrow blood vessels. ARBs, meanwhile, help blood vessels avoid constriction by blocking receptors to which angiotensin attaches.

African caribbeans produce less renin. So there is less ACE circulating anyway. So no point giving ACEI. But instead give ARB which blocks the receptor onto which the remaining low levels of ACE attach. I think that's the theory.

But from what I can see on the research front – this is not seen in real practice. The only good thing about ARB over ACEI is less side effects. So perhaps they're trying to increase concordance. But then why not do this for everyone?

WHEN TO STEP UP TREATMENT

Add additional therapy if BP > TARGET (consider clinical judgement and patient tolerance)

If have confirmed diagnosis of hypertension, amend medication based on clinic reading, do not delay by repeating BP readings or awaiting home BPs unless strong hx of white coat effect.

NB: HCA/NURSES – FOLLOW MEASURING BP PROTOCOL OF WHEN TO REFER A RAISED READING BACK TO GP

TARGETS

• <130/80 if the patient has other Chronic Disease (CVD/DM/CKD/TIA/CVA/PVD)
• <140/90 if only hypertension
• <150/90 if over 80 years for all conditions

WHAT TO DO IN A BP REVIEW APPOINTMENT

• Monthly review WITH treatment change until BP below target, thereafter annual BP review, bloods and medication review as per CDM review table
• Lipid Rx: As per lipid modification protocol
• Consider ABPM/HBPM as an adjunct to clinic BP measurements to monitor the response to anti-hypertensive treatment with life-style modification or drugs, if increasing medication will be poorly tolerated, avoiding polypharmacy, white coat effect, patient resistance
• Hypertension in women of childbearing age/Hypertension in Pregnancy: Refer to appropriate NICE guidance 107

Follow-up and Monitoring

• Monthly reviews until target BP achieved
• Then 3-6 monthly when stable
• Annual minimum review (BP, CVD risk, lifestyle)
• Check U&E 2 weeks after starting/changing ACE-I/ARB
• Home BP monitoring encouraged

SICK DAY RULES - Advice re: AKI

Advise patients the following to prevent ACUTE KIDNEY INJURY/DAMAGE when they are unwell

If you do go down with a cold, flu or any other illnesses like vomiting or diarrhoea (unless only minor)…

The Basics:

• Rest
• Drink plenty of sugar-free fluids
• Avoid too much caffeine as this could make you dehydrated
• Take painkillers in the recommended doses as necessary
• Contact your GP to see if treatment with antibiotics is necessary
• If you are vomiting uncontrollably, contact your GP or urgent medical services (111 or A&E if in the UK)

Stop taking the medications listed below (Mnemonic: DAAMN):

• DIURETICS – furosemide, spironolactone, indapamide, bendroflumethazide
• ACE-inhibitors – lisinopril, perindopril, ramipril
• ARBs – losartan, candesartan, valsartan
• METFORMIN
• NSAIDs – ibuprofen, diclofenac, naproxen

Restart the medication when you are well

Usually 24-48 hours of eating and drinking normally

💓 Comprehensive Heart Failure Management

SYMPTOMS

• Breathlessness on exertion and at rest + reduced exercise tolerance
• Orthopnoea, PND (Paroxysmal Nocturnal Dyspnoea)
• Nocturia
• Swollen ankles, Swollen abdo (patients say bloating and weight gain)
• Increasing fatigue (+/- lightheadedness/syncope)

EXAMINATION SIGNS

• Tachypnoea (SOB)
• Tachycardia >100 bpm
• High BP
• Auscultation Lungs: Fine basal crepitations +/- pleural effusion
• Auscultation Heart: laterally displaced apex beat and heart murmur, Gallop Rhythm at the apex (3rd/4th heart sounds)
• Fluid retention: ankle, abdominal, sacral oedema

RISK FACTORS

• Age >65
• IHD, hypertension, AF, valvular heart disease, cardiomyopathy, myocarditis
• Renal failure
• Anaemia
• Thyrotoxicosis

Don't forget…

• Family HX of heart failure + sudden cardiac death under the age of 40 years

Drugs that can cause/worsen HF

Drugs that can cause HF:

• Alcohol
• Cocaine

Drugs that can worsen HF symptoms (Mnemonic: NET CCC):

• NSAIDs like ibuprofen, naproxen
• Effervescent preparations e.g. eff Solpadol (high sodium content)
• Tricyclics antidepressants like amitriptyline
• Ca Channel Blockers like Diltiazem
• Corticosteroids like prednisolone
• COX II inhibitors like celecoxib

INVESTIGATIONS

• Blood tests: FBC, U+Es, TSH, LFT, HbA1c, lipid profile, BNP
• Urine dip for blood and protein
• ECG
• CXR
• Spirometry/Peak flow (to exclude lung causes of SOB)
• ECHO – see diagnosis section

If LVSD already confirmed via previous ECHO then bloods performed to assess for contraindications to medications

Previous MI

URGENT referral HF clinic and ECHO within 2/52

Symptomatic HF with no previous HX of MI:

Measure NT-proBNP (NICE & ASSIST)

>2000 pg/ml (236 pmol/l)

URGENT REFERRAL for specialist assessment + ECHO in 2 weeks

400 – 2000 pg/ml

Refer for specialist assessment + ECHO in 6 weeks

<400 pg/ml

Diagnosis of HF less likely – Consider discussion with specialist if still symptomatic

Special Cases

• Pregnant women (or women 6 months post-natal) with suspected HF: emergency admission/refer specialist
• HF with valve disease: refer for specialist assessment

BEWARE: Other causes of a raised BNP

• Age >70
• Other cardiac things – LVH, Ischaemia, Tachycardia, RV overload
• Hypoxaemic conditions – e.g. COPD, PE
• Renal: when GFR <60
• Diabetes
• Liver Cirrhosis
• Sepsis

BEWARE: BNP levels are reduced by

Heart failure treatment – such as ACE, diuretics and beta-blockers

NYHA CLASSIFICATION

Grade I: No limitations

Grade II: Some limitation of normal activity (15% mortality at 12 months)

Grade III: Severe limitation of normal activity (30% mortality at 12 months)

Grade IV: SOB at rest (60% mortality at 12 months)

Classification is important as it defines prognosis and optimal treatment – it must be recorded in all cases using the specified Read code.

MANAGEMENT STEPS

Loop Diuretic
ACEI or B blocker – only one at a time. ACEI if patient has DM or fluid overload. BB if patient has angina. BB worsen fluid overload.
ACEI & B Blocker
For all – LIFESTYLE – stop smoking, reduce alcohol, low salt diet, avoid salt substitutes as well, if obese lose weight, supervised gradual exercise
One off pneumococcal vaccine & annual flu jab

Some Key Rules

• Review medications that can worsen symptoms – NSAIDs, Calcium channel blockers
• ONLY ADD 1 DRUG AT A TIME – according to clinical judgement
• HF with preserved EF – manage co-morbidities (HTN/IHD/DM) in line with NICE guidelines
• HF due to left ventricular systolic dysfunction – 1st line management ACEi (or ARB) + Beta blockers

WHEN TO REFER

• All new diagnosed cases
• Symptomatic despite above treatment
• Managing severe HF (NYHA class IV), HF not responding to treatment
• HF due to valve disease
• HF which can no longer be managed at home
• Pregnant or preconception

BNP <100pg/ml

Heart failure unlikely

Consider other causes of symptoms

BNP 100-2000pg/ml

Echo within 6 weeks

Routine cardiology referral

BNP >2000pg/ml

Echo within 2 weeks

Urgent cardiology referral

NT-proBNP Equivalents

Use higher thresholds: <300pg/ml (unlikely), 300-6000pg/ml (routine), >6000pg/ml (urgent)

DIURETICS - Primarily used for symptom control

Once pulmonary congestion and oedema controlled and established HF treatment on board, diuretics can be stopped.

Daily self-weighing can be a useful guide as to whether fluid is collecting and diuretics are needed. Advise patients to contact their GP if more than 1.5-2 kg weight gain in 2 days.

• Titrate dose ↑ or ↓ according to symptoms
• Measure renal function + BP before initiating medication and 1-2 weeks after starting treatment (NICE)
• Earlier monitoring in 5-7 days in those with existing CKD stage 3 or higher and in those >60 years (NICE)

Recommended Loop Diuretic (NICE)

Medication	Elderly Dose	Usual Dose
Furosemide	20 – 40 mg	20-120 mg
Bumetanide	0.5 – 1 mg	1 – 5 mg
Torasemide	5 – 10 mg	10 – 20 mg

For patients with confirmed HF + preserved EF: MAXIMUM DOSE FUROSEMIDE 80 mg (NICE)

Patient Education

• Educate patients to adjust dose according to weight — DISCUSS with GP if weight gain 1.5-2 kg gain/2 days
• Avoid excessive fluid intake — 1.5 litre fluid intake per day (ASK them to maintain a fluid diary)

IF develops D&V:

• Maintain fluid intake
• STOP diuretic for 1-2 days until recovered
• If persistent >2 days — then contact GP — will need bloods (renal) + BP +/- referral to secondary care
• Re-initiating diuretic — start at lower dose

ONCE Rx stabilised

Measure U&Es at least once every 6 months (NICE)

Other means of symptom control for breathlessness

• Oramorph/lorazepam
• Hand held fan
• The palliative care team are a useful resource for advice and support regarding symptom control

CONTRAINDICATED

• if Cr >150, K+ >5.5 and/or renal artery stenosis
• Angioedema
• Significant aortic stenosis or valvular disease
• In all these situations, refer

CAUTION in women of childbearing age and contraindicated if trying to conceive or pregnant

If U&Es pre treatment reveal Cr <150 micromol/l, K+ <5 and Na+ >130 mmol/l then:

• 2.5 mg Ramipril daily (1.25mg if on concomitant diuretics) for one week with check U&Es
• Then increase to 5.0 mg Ramipril for a further three weeks
• Re-check U&Es 1-2 weeks after each dose increment and attempt to up titrate all patients to the 10mg dose
• Thereafter repeat U&Es on an annual basis

If eGFR change >25% or Cr rise >30%:

• Ix for other causes e.g. concurrent NSAID or fluid depletion
• If no concurrent cause found either stop ACEi or reduce to previously tolerated dose

Patients intolerant of ACEi

• Can try an ARB e.g. Candesartan
• ARB may also be used in addition to ACE in patients with severe HF (NYHA 3 and 4) who continue to be symptomatic
• Recent evidence suggests that Candesartan may have benefits over other ARB licensed for HF (currently Losartan)

If intolerant to ACEI & ARB

Refer to secondary care or consideration of hydralazine & nitrate

If K+ >6

STOP ACEI/ARB

WARN patients improvement in symptoms over weeks to months

BISOPROLOL

In addition to normal treatment NYHA grade I, II and III should have a trial of a betablocker e.g. bisoprolol

This should include patients with COPD, PVD, diabetes and ED.

This should be a slow up-titration with regular review – consider referral to the Heart Failure Nurse Practitioner.

Bisoprolol (mg) UPTITRATION

Week	Dose (mg)
WEEK ONE	1.25
WEEK TWO	2.5
WEEK THREE	3.75
WEEK FIVE	5
WEEK EIGHT	7.5
WEEK TWELVE	10

Consider back dose titration if the patient develops:

• Symptomatic hypotension
• Asymptomatic systolic BP <90mmHg
• Bradycardia <50bpm
• Respiratory symptoms

2nd Line Treatments

• Aldosterone Antagonists e.g. spironolactone (K+ needs to be less than 6)
• ARB in conjunction with ACEi
• Hydralazine nitrate (esp if African/Caribbean's and those intolerant to ACEi/ARB)

3rd Line Treatments

• Cardiac Resynchronisation
• ICD – implantable cardiac defibrillator
• CABG, LV assist device, cardiac transplant
• Digoxin
• Ivabradine
• Entresto (Sacubitril/Valsartan)

SPIRONOLACTONE

• Avoid in renal impairment and/or diabetic nephropathy
• Monitor U&E's 6 MONTHLY
• HALVE dose if K+ rises between 5-5.9
• STOP if K+ >6 or Cr >220

IVABRADINE

• NOT USED IN ARRHYTHMIAS
• SA node inhibitor
• Pulse has to be 75 or more, sinus rhythm
• Only initiated after 4 weeks stabilisation period on standard therapy

DIGOXIN

Routine digoxin levels not needed unless toxicity suspected, in which case, levels should be taken 8-12 hours post dose. BEWARE toxicity can still occur with normal digoxin levels.

Symptoms of toxicity include:

• Arrhythmia, anorexia, nausea, vomiting, diarrhoea
• Confusion, yellow vision, blurred vision, photophobia

CARDIAC RESYNCHRONISATION

Paces both ventricles and Rt atrium to improve contraction

EPLERENONE

• Patients with acute MI & LVD benefit from Eplerenone (an aldosterone antagonist) post MI, so you may see some patients discharged on this
• Can also be given if patients develop gynaecomastia on spironolactone

ENTRESTO (Sacubitril/Valsartan)

• New class of drug – ARNI (angiotensin receptor-neprilysin inhibitor)
• Neprilysin inhibition affects the ability of natriuretic peptides to cause vasodilatation and also inhibits the renin-angiotensin system and has an anti-hypertrophy effect
• NOT used with ACEI/ARB

THE HEART FAILURE REVIEW (MONITORING)

• Pulse, BP & BMI
• ECG
• Update NYHA classification
• Medication review, assign diagnosis to repeat template
• Smoking status/cessation advice
• Alcohol intake and advice
• Lipid modification
• Annual Flu vaccination and Pneumovac
• Bloods as per CDM review table within the last 12 months (CDM = chronic disease management)
• Add recall

PALLIATIVE CARE

• Consider palliative and end of life care when appropriate to do so, usually in patients with advanced heart failure with on-going symptoms despite optimal management
• Consider low dose opioids, titrated against effect, in patients with dyspnoea

SICK DAY RULES

Advise patients the following:

Tummy bugs which result in vomiting and/or diarrhoea can easily lead to dehydration. Even flu-like symptoms and coughs and colds with a fever can lead to dehydration through increased sweating.

When you are dehydrated, certain drugs for heart failure can be harmful.

These drugs should be temporarily stopped to prevent subsequent side effects.

You can restart these medications once you are feeling better

Medications to stop:

ACEi/ARB/Diuretics/other antihypertensives/NSAIDs

If symptoms persist >2 days, call doctor to reassess

Also…

• Avoid too much caffeine as this could make you dehydrated
• Keep weighing yourself on a daily basis to help your heart failure specialist adjust your medication while you are dehydrated
• It may be adequate to slightly and temporarily increase your fluid intake during the dehydration period, but return to your usual daily limit as soon as your dehydration state is resolved and follow the directions of your heart failure specialist
• Over-the-counter anti-inflammatory drugs such as ibuprofen, diclofenac (eg. Voltaren emulgel®) or naproxen must be avoided to treat fever or pain. Acetaminophen remains the preferred option in such situation

WARNING: Some over-the-counter products for cold and flu contain anti-inflammatory ingredients. Always refer to your pharmacist before using such products.

What the doctor should do:

• Assess hydration status – tongue, skin turgor etc – and do a BP
• Stop medications: ACEi/ARB/Diuretics/other antihypertensives/NSAIDs for 1-2 days; restart when eating and drinking normally (NICE)

If symptoms persist >2 days

• Continue to withhold meds
• Do some obs – T, Pulse, BP, O2 sats
• +/- Refer to secondary care

Signs of dehydration

MILD dehydration

• Dry mouth
• Light-headedness
• Headache

SEVERE dehydration

Also includes the symptoms mentioned above, plus…

• Intense thirst
• Lower blood pressure than usual
• Reduced urine output and darker urine

Weigh yourself at home

• Same time per day
• If weight ↑ >2 kg in 3 days – advise ↑ diuretic dose and ↓ fluid intake

Salt Consumption

• Do not exceed >6 grams per day
• Direct patient to British Heart Foundation + British Dietetic Society

Fluid Balance

In severe symptoms RESTRICT to 1.5 – 2 litres per day

Smoking Cessation

Encourage and support smoking cessation

Alcohol

Stick to recommended levels

Exercise

Regular low intensity physical activity if stable HF

END STAGE HF (Taken from NICE & ASSIST 2023)

Symptoms

Main symptoms:

• Breathlessness, persistent coughing, cardiac ischaemia pain, intense fatigue
• Severe limitation of physical activity & oedema

Other symptoms:

• Loss of appetite & nausea, constipation
• Depression & anxiety, insomnia

Management

• Liaise with cardiology + Palliative care
• Discuss ADVANCED CARE PLANNING + DNACPR early

Predicting treatment trajectory

Can be difficult to predict, but base on:

• Frequent hospital admissions: 3 or more admissions in last 12 months
• Poor response to Rx, breathlessness (NYHA IV)
• Presence of cardiac cachexia, ↓ serum albumin
• Progressive ↓ eGFR + hypotension
• Poor quality of life + dependence on others for ADL
• On home O2

USEFUL MEDICATIONS IN PALLIATION:

Breathlessness:

• Low dose oromorph/Lorazepam/Diazepam
• Can use GTN spray but contraindicated in severe aortic stenosis

Cardiac ischaemia pain:

• Morphine + nitrates

🧠 Stroke and TIA Recognition & Management

DIAGNOSING A STROKE

Carers may use FAST tool to assess symptoms:

FAST Assessment

• Facial weakness – can they smile, is face drooping?
• Arm weakness – can the person raise both arms?
• Speech problems – can they speak clearly and understand what you are saying?
• Time to call 999

Differentials (MESH-D)

• Migraine
• Epilepsy
• Sepsis
• Hypoglycaemia
• Other causes of Delirium (alcohol, drugs, dehydration, dementia, UTIs, LRTIs, medicines, and advanced cancer)

If you suspect a Stroke

• Admit to hospital – Call 999
• Do not give Aspirin pending scan and possible thrombolysis

TIA - HOW IT DIFFERS FROM A STROKE

A TIA is a brief blockage of blood flow to part of the brain, spinal cord or the thin layer of tissue at the back of the eye known as the retina. This blockage may cause temporary stroke-like symptoms.

But a TIA doesn't damage brain cells or cause permanent disability. This is how it differs from a regular stroke.

ASSESSMENT & MANAGEMENT OF TIA IN PRIMARY CARE

Assessing the risk of stroke post TIA using the ABCD2 score

ABCD2 SCORE TABLE

Component	Criteria	Points
A (Age)	≥60	1 POINT
A (Age)	<60	0 POINT
B (BP)	>140/90	1 POINT
C (Clinical features)	Unilateral weakness	2 POINTS
	Dysphasia	1 POINT
	Other symptoms	0 POINTS
D (Duration of symptoms)	≥ 60 minutes	2 POINTS
	10-59 minutes	1 POINT
	< 10 minutes	0 POINT
D2 (Diabetes)	Yes	1 POINT
D2 (Diabetes)	No	0 POINT

NICE recommends ALL suspected TIA to be referred without risk stratification ABCD2 score

However Bradford still uses the ABCD2

In Bradford, what you do depends on the ABCD2 score and frequencies of TIA

Suspected TIA AND ABCD2 score ≥4 OR ≥2 TIAs in a week

Refer TIA clinic using updated form (on ASSIST) and fax form through asap as they need evaluation within 24 hours. There may be a telephone number to use to speak to consultant on call.

Suspected TIA AND ABCD2 score <4

Refer to TIA clinic using the updated form – should be seen within 1 week

Suspected TIA presenting after 1 week

Refer to TIA clinic – should be seen within 1 week of referral

Other Important Management Things

• If symptoms persist throughout your clinical examination, send patient to A+E (could be a stroke!)
• All patients with suspected TIA should be given 300mg Aspirin immediately and then continued as 75mg daily until they are seen in the TIA clinic. Can also offer Clopidogrel 75mg instead of Aspirin – preferred choice in Bradford
• TIA patients should not drive for one month – or until seen in the TIA clinic and told otherwise – document this advice
• Any witnesses to the event should accompany patient to clinic
• If experiences a further event before being seen in TIA clinic – go to A+E

Exclusion criteria for TIA clinic

• Age <45 – refer Neurology
• Loss of consciousness
• Falls
• Dizziness
• Confusion
• Incontinence
• Amnesia
• Isolated vertigo/diplopia/dysarthria
• Sensory symptoms confined to part of one limb or face

A reminder about Prevention Types

Primary prevention: Aims to prevent disease before it ever occurs. Examples: immunising people, statin in patients with high QRISK but no PMH of IHD

Secondary prevention: Aims to reduce the impact of a disease that has already occurred. Examples: clopidogrel for patients already had a stroke, low dose aspirin patients already had an MI

Tertiary prevention: Aims to soften the impact of an ongoing illness that has lasting effects. Examples: cardiac or stroke rehabilitation programs, chronic disease management programs

Primary Prevention of Stroke

• Maintaining a normal BP
• If QRISK >10% consider atorvastatin 20mg (NICE) or 40mg (BHH)
• If known IHD then lipid management decreases the risk of stroke, Atorvastatin 80mg
• All patients with valvular heart disease and AF should be considered for warfarin/NOAC. Only use the CHA2DS2VASc score to determine anticoagulation use in patients with non valvular AF
• Healthy lifestyle advice – diet, alcohol, exercise and smoking cessation advice and treatment

Secondary Prevention of Stroke

i.e. preventing the high risk ones from getting it

• AF should be assessed and treated with warfarin/NOAC
• BP – should be maintained at <130/<80 (BHH) (unless they have bilateral coronary artery stenosis <150/90). BP lowering therapy if needs be
• All patients with a history of Ischaemic stroke should be on Clopidogrel in preference to low dose aspirin, as this reduces CVS mortality and recurrent stroke
• Patient's with post ischaemic CVA should receive Aspirin & Dipyridamole if clopidogrel not tolerated or contraindicated
• Statins – all patients with a history of TIA/ischaemic stroke irrespective of age, sex or cholesterol level should be given Atorvastatin 80mg
• Smoking cessation and healthy lifestyle advice
• All patients with non disabling stroke or TIA should be considered for urgent specialist assessment – patients with high grade ipsilateral stenosis benefit from carotid endarterectomy

STROKE PREVENTION IN AF - CHA2DS2-VASc

Code	Condition	Points
C	Congestive heart failure (or Left ventricular systolic dysfunction)	1 POINT
H	Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)	1 POINT
A2	Age ≥75 years	2 POINTS
D	Diabetes Mellitus	1 POINT
S2	Prior Stroke or TIA or thromboembolism	2 POINTS
V	Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)	1 POINT
A	Age 65–74 years	1 POINT
Sc	Sex category (i.e. female sex)	1 POINT

The maximum CHA2DS2-VASc score is 9 (not 10, as might be expected from simply adding up the columns because the maximum score for age is 2 points = 0 if <65, 1 if 65-74, 2 if ≥75)

CHA2DS2-VASc Score & Annual Stroke Risk

Score	Estimated Annual Risk of Stroke	Risk Level
0	0.2%	LOW RISK
1	0.5-1%	LOW RISK FOR FEMALES, LOW-MED RISK FOR MALES
2	2-3%	LOW MOD RISK FOR FEMALES, MOD HIGH RISK FOR MALES
3	3-4%	MODERATE HIGH RISK FOR ALL
4	5-6%
5	7-10%
6	10-13%
7 or 8	11-15%
9	12-18%

Important Notes

• Different stroke studies say different things about annual stroke risk rates based on CHA2DS2VASc score. This table shows an average but the confidence intervals can be wide
• Stroke rates vary by study setting (hospital vs community), population (trial vs general), ethnicity, etc
• The predictive abilities of risk scores for ischemic stroke in patients with kidney function impairment is questionable
• Anticoagulation basically reduces the risk by about 50%. So, someone with a 4% annual stroke risk prediction, on anticoagulation will have a 2% annual stroke risk prediction
• Please note, putting someone on anticoagulation therapy does NOT eliminate the annual stroke risk – it reduces it
• Don't forget there is a bleed risk with anticoagulants of roughly the order of 2-3% per year. Some of these will prove fatal – see HASBLED score
• All these things should be explained to the patient so they can make the appropriate choice for them as individuals

HAS-BLED SCORE FOR ASSESSING MAJOR BLEED RISK

Code	Condition	Points
H	Hypertension: (uncontrolled, >160 mmHg systolic)	1 POINT
A	Abnormal renal function: dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L	1 POINT
A	Abnormal liver function: cirrhosis or bilirubin >2x normal or AST/ALT/AP >3x normal	1 POINT
S	Stroke: prior history of stroke	1 POINT
B	Bleeding: prior major bleeding or predisposition to bleeding	1 POINT
L	Labile INR: unstable or high INR or Time in Therapeutic Range <60%	1 POINT
E	Elderly: age >65 years	1 POINT
D	Drug Medication – such as antiplatelet agents, SSRIs, NSAIDs (i.e. predispose to bleeding)	1 POINT
D	Alcohol (≥ 8 drinks/week)	1 POINT

A calculated HAS-BLED score is between 0 and 9

HAS-BLED Score & Bleeding Risk

Score	Bleeds per 100 patient years
0	1 bleed per 100 patient years
1	1 bleed per 100 patient years
2	2 bleeds per 100 patient years
3	4 bleeds per 100 patient years
4	9 bleeds per 100 patient years
5	10 bleeds per 100 patient years
6, 7, 8, 9	Too rare to determine accurate risk. Most likely over 10 percent will bleed

The HAS-BLED score estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.

A score of ≥3 indicates "high risk", but does not necessarily mean that an anticoagulant cannot be given, as some risk factors may be modified. Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.

POST HAEMORRHAGIC STROKE

• Anti-platelets not recommended unless very high risk CVD risk
• Statins are not routinely recommended
• Specialist advice recommended
• BP lowering non acutely, as for ischaemic stroke

DON'T FORGET CODING

• Read code STROKE/TIA for QoF
• Promote to problem and summary lists
• Use appropriate S1 template/ARDENS
• Add recalls for annual CDM review
• Assign diagnosis to repeat template drugs

THE ANNUAL STROKE REVIEW

Do the following:

• Bloods: U+Es, HbA1C plus (ALT at 3 months only if new or dose change of statin)
• BP: follow hypertension protocol
• BMI
• Medication: ask about medication concordance & side effects, move review dates on, record medication review done
• Depression screen
• Lifestyle things: smoking status & cessation advice, alcohol advice
• Carer details – any additional help required – ask carer how things are

Don't forget…

• Do all of this by completing the S1 template (ARDENS)
• See CDM review table
• Nurses to follow Nurse led clinic protocol
• Add Medication Reviewed & assign diagnosis to appropriate repeat meds
• Move recall on

💊 Comprehensive Lipid Management & Statin Therapy

BEWARE IF THE LDL CHOLESTEROL IS REALLY HIGH

If a patient's LDL is really high, then do they have a FH (Familial Hypercholesterolemia) with variable penetrance?

In that case, we are then really in a secondary prevention conversation.

Classification is important as it defines prognosis and optimal treatment – it must be recorded in all cases using the specified Read code.

STATINS AND NON-CARDIAC BENEFITS

Statins might do loads of other advantageous things:

Vascular Anti-inflammatory Effects

They are vascular anti-inflammatory and they may reduce your risk of an ICU admission if you had Covid-19 for instance (CVD without statin increased your risk, but it was not a return to the median, they were beneficial).

Anti-cancer Properties

The anticancer properties of statins have been found in various cancers. In a large Danish cohort, compared with patients who had never used statins, statin users presented with significantly reduced cancer-related deaths for 13 different cancer types, including breast cancer.

A recent advance has been to implicate statins in potentiating anti-tumor immune responses in cancer.

The Bottom Line

The majority of people in the UK will die of either cancer or CVD, then surely reducing the risk of one of these is enough! (PS They reduce the risk of metastatic spread as well)

WHAT ABOUT MUSCLE PAINS WITH STATINS

Muscle pains is slightly more complex. Atorvastatin and Simvastatin are more lipophilic than Rosuvastatin and Pravastatin (does anyone seriously use Pravastatin any more???) but this does not seem to be the simple solution to muscle pain…just use rosuvastatin.

In reality you should:

1. Always start with atorvastatin

• 40mg primary prevention
• 80mg secondary prevention

2. If muscular pain, check CPK and stop

We really should check the CPK as if this is raised you should not really reintroduce a statin. Also if elevated important to recheck 4-6 weeks later as you will find those who have elevated levels not due to statins

3. If CPK is acceptable wait 6-8 weeks and see if the pain settles

(Most it makes no difference as it was never the statin in the first place)

If not we have 2 choices:

• Option A: Give the same statin back but up titrate to the previous dose over a few weeks. Over 70% will be able to take the previous statin without pains. However this suggestion usually get quite a blunt response from our Yorkshire patients, often resorting to their Anglo-Saxon linguistic roots!
• Option B: Give them a statin from the other family. Most of us in the UK only use atorvastatin and rosuvastatin – this makes life easier; if they have had atorvastatin give them rosuvastatin and vice versa

WHAT ABOUT PATIENTS NOT KEEN ON STATIN BECAUSE OF MEDIA PRESS AND WANT TO TRY PLANT STEROLS LIKE IN MARGARINES

But what if the patient doesn't want a statin because of the exaggerated bad media press? Or what about those patients who say they want to give it a go themselves first or with more natural things like plant sterols?

Primary Prevention Setting

If a person in primary prevention wishes to amend their diet, that is up to them. Statins have evidence in a primary prevention setting and all the rest is window dressing, and in the case of plant sterols – like you find in margarines and yoghurts – very expensive window dressing!

The food industry has created a multi-million-pound market out of the desire to cut cholesterol. Studies have shown that margarines such as Benecol and Flora pro.activ can reduce the level of harmful fats in the blood. But they are also up to four times as expensive as conventional margarines.

They often claim a 14-15% reduction just after four weeks – but only if patients use enough spread to cover four slices of bread daily!!!!

Better Approach

If people really want to address their lipids in a primary prevention setting, they will do better watching their alcohol and refined carbohydrate most of the time.

SECONDARY PREVENTION IN PATIENTS STILL NOT KEEN ON STATINS

Secondary prevention is harder.

• 1 in 4 people die immediately from their infarct, and this is getting worse again
• Of those who survive the initial acute event nearly ALL will die of vascular events

The Reality

All their health risk is before them (well they aren't dead yet) and if you want to reduce the risk, take the tablets and improve your lifestyle. Yes lifestyle change will reduce risk but this is in addition to the medication.

If a patient chooses to not take meds, then that is a patient's choice, but it is important that they understand that their risk of further events has increased. It is that simple.

The Flak Jacket Analogy

If you are a patient who has already had a heart attack or other cardiovascular event, then you are at war with cardiovascular disease. Whether you like it or not, you have entered the fire fight.

Being one of the lucky ones who has survived say a heart attack, is a bit like a bullet which has hit your arm. Being on a statin is a bit like having a flak jacket.

Do you really want to take it off knowing other bullets are heading your way?

PS a flak jacket = a sleeveless jacket made of heavy fabric reinforced with metal or Kevlar, worn as protection against bullets and shrapnel.

🌙 Culturally Sensitive Cardiovascular Care During Ramadan

RAMADAN AND FASTING ADVICE FOR CARDIOVASCULAR DISEASE

Fasting is an obligation for competent, healthy adult Muslims although there are exemptions. Many of those who could seek exemption might still want to fast. It is important to respect this but it is advisable to start planning 6-8 weeks before Ramadan to avoid adverse outcomes e.g. patient self-adjustment of medication.

About Ramadan Fasting

The fast of Ramadan lasts from dawn to sunset for a period of 29 or 30 days. It follows the lunar calendar so is brought forward by about 10 days each year.

Fasting people generally eat two meals a day: often a smaller meal before dawn (Suhoor) and a larger one after sunset (Iftar). No fluids or food are taken during daylight hours. This includes water and most medication.

Who is exempt from fasting?

• Acute or chronic illness
• Travellers
• Pregnant/breastfeeding*
• Menstruating/postpartum bleeding
• Children
• Mentally unwell/lacks capacity

*Consensus by Islamic scholars that it is permissible not to fast if there is threat of harm to mother/child

Permissible interventions/medications

• Blood tests
• Vaccinations
• Asthma inhalers*
• Ear drops*
• Eye drops
• Transdermal patches

*Difference of opinions exist. Encourage patients to contact their local imam, or BIMA for advice.

Should I advise my patient not to fast?

BIMA have an interactive traffic light tool that help to classify patients into low/moderate risk, high risk, and very high risk at www.britishima.org/Ramadan-compendium in chapter 6.

Patients in the two higher tiers should be advised that they 'must not fast' and 'should not fast' respectively. Consider advising these patients to fast in the shorter winter months. If they insist to fast, monitor regularly and ask that they should be prepared to break the fast in case of adverse events.

V. HIGH RISK – MUST NOT FAST

• Advanced heart failure EF <35%
• Severe pulmonary hypertension

HIGH RISK – SHOULD NOT FAST

• Poorly controlled hypertension
• Recent ACS <6 weeks
• HOCM
• Severe valvular disease
• Poorly controlled arrhythmias
• Implantable cardioverter defibrillator

LOW RISK – Individual decision

• Stable hypertension
• Stable angina
• Mild heart failure
• PPM (Permanent Pace Maker)
• SVT/AF

You've Got This! 💪

Remember: You don't need to be a cardiologist to provide excellent cardiovascular care. You just need to know when to worry, when to treat, and when to refer.

Trust your clinical skills, use the tools available (QRISK3, BNP, ECG), and don't hesitate to seek advice when needed. Every patient interaction is an opportunity to prevent cardiovascular disease - and that's incredibly powerful.

Now go reward yourself with that well-deserved coffee ☕

Last updated: November 2025 | Based on latest NICE, ESC, and SIGN guidelines

For GP trainees by GP trainers - making cardiovascular medicine accessible and practical

🫀 CARDIOVASCULAR MEDICINE for GPs: Your Survival Guide

Executive Summary: What You'll Master Today

What This Page Covers:

Quick Facts at a Glance:

Quick Navigation

📥 Downloads

🌐 Web Resources

Brainy Bites: Essential Cardiovascular Wisdom

Key Questions for Data Gathering

Red Flags – What Not to Miss!

1. Red Flags & Conditions Not to Miss

2. Diagnostic Approach & Investigations

Stepwise Approach to Key Symptoms

Chest Pain (SOCRATES)

Breathlessness Assessment

Focused Cardiovascular Examination

General Inspection

Pulse & BP Assessment

Precordial Examination

When and How to Use Risk Calculators

QRISK3

CHA₂DS₂-VASc

HAS-BLED

Appropriate Use of Investigations

ECG Indications

BNP/NT-proBNP

Troponin

Recognising When to Refer Urgently

Interpreting Secondary Care Results

Echo Reports

Angiography Results

3. Differential Diagnosis Frameworks

Chest Pain Differential Diagnosis

Cardiac Causes

Respiratory Causes

Non-Cardiac Causes

Red Flag Features

4. Common Conditions

Hypertension & Cardiovascular Risk Management

NICE NG136 Diagnostic Criteria

When to Offer ABPM/HBPM

Stage 1

Stage 2

Stage 3 (Severe)

Treatment Thresholds

First-Line Treatment (NICE 2024)

Follow-up Schedule

Target BP

5. Hypertension at a Glance

NICE NG136 Definitions

BP Targets

Proper BP Measurement Technique

White Coat Hypertension

Clinically Significant White-Coat Effect

SEVERE HYPERTENSION: BP >180/120

IF NO SYMPTOMS & NO EXAMINATION SIGNS

IF SYMPTOMS AND/OR TARGET ORGAN DAMAGE SIGNS

MALIGNANT (ACCELERATED) HYPERTENSION: BP >220/120

NICE Treatment Algorithm

COMORBIDITIES - WHICH HTN RX ARE BETTER?

CKD (Chronic Kidney Disease)

Chronic Heart Failure

Type 2 Diabetes

Type 1 Diabetes

Atrial Fibrillation

The Term African Caribbean

SPECIAL CASE: AFRICAN CARIBBEANS

Why ARB instead of ACEI?

WHEN TO STEP UP TREATMENT

TARGETS

WHAT TO DO IN A BP REVIEW APPOINTMENT

Follow-up and Monitoring

SICK DAY RULES - Advice re: AKI

6. Heart Failure at a Glance

SYMPTOMS

EXAMINATION SIGNS

RISK FACTORS

Don't forget…

Drugs that can cause/worsen HF

INVESTIGATIONS