Cardiology
Chest pain referral
- Current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
- Chest pain 12-72 hours ago: refer to hospital the same-day for assessment
- Chest pain > 72 hours ago: perform full assessment with ECG and troponin to decide further management
Angina
- Constricting pain in chest/neck/arm precipitated by exertion, relieved by rest or GTN
o Typical = all 3, atypical = 2 of 3
- Acute management: GTN for symptom control. Take again after 5 min, if not better 5 min after second dose call 999
- Preventative treatment for stable angina:
o 1st line = BB or CCB (diltiazem, verapamil)
o 2nd line (if both not tolerated/contraindicated) = long-acting nitrate e.g. ISMN, nicorandil, ivabradine,
ranolazine.
o Consider aspirin 75mg (people with stroke or PAD should continue clopidogrel instead of aspirin)
o Consider ACEi if diabetic, CKD, HF, previous MI
o Offer statin
o Offer anti-HTN meds
- Uncontrolled symptoms = combination treatment:
o BB + long acting CCB e.g. amlodipine, MR nifedipine, MR felodipine
o BB + nitrate (if CCB not tolerated/contraindicated)
▪ Stop ivabradine if no improvement after 3 months and seek specialist advice
o Long acting CCB + nitrate (if BB not tolerated/contraindicated)
▪ Do not combine BB with rate-limiting CCB due to risk of bradycardia
▪ Do not combine ivabradine with a rate-limiting CCB due to risk of excessive bradycardia
- Refer if symptom control is poor on 2 drugs. Consider starting third anti-anginal while waiting specialist assessment
- Stable angina: refer to RACPC
- Consider hospital admission for unstable angina (pain at rest, pain on minimal exertion, angina progressing rapidly
despite medical treatment)
- All patients with angina should have CT coronary angiography
MI
- Acute MI -> admit via 999 but in the meantime give:
o Oxygen if sats <94% -> face mask, 5-10L, target sats 94-98%
▪ If CO2 at risk of hypercapnia -> use 28% Venturi, 4L flow rate, target sats 88-92%
o Aspirin 300mg
o Analgesia if available: GTN and/or opioid
o Do 12 lead ECG but do not delay hospital transfer
- Pain >72 hours ago, now pain-free & no complications, consider diagnosing in primary care
o ECG
o Troponin
o Refer to be seen within 2 weeks
- Lifestyle advice
o 150 min moderate intensity exercise per week, 2 sessions muscle strengthening exercise per week
o 4-5 portions (30g) of unsalted nuts/seeds per week
o Total fat intake <30%, saturated fat <7%. Diet supplementation with omega 3 NOT recommended
o 2 portions of fish per week. 5 portions fruit/veg per week
o Salt <6g/day
o Stop smoking, alcohol <14 units
- Cardiac rehabilitation programme with exercise, health education & stress management for all patients
- Secondary prevention:
o ACEi (not in pregnancy or breastfeeding)
o BB
o DAPT: aspirin + [ticagrelor or clopidogrel if high bleeding risk]
o Statin (usually atorvastatin 80mg)
- Acute MI with sx of HF and LVSD: aldosterone antagonist e.g. eplerenone should be initiated
- Annual flu vaccine
- Sexual intercourse after 4 weeks. Sildenafil can be used after 6 months (unless on nitrates/nicorandil)
- Complications:
o Pericarditis: central chest pain, worse on inspiration & lying flat, relieved by leaning forward. Pericardial
friction rub. ECG: saddle shaped ST elevation +/- PR depression. Mx: NSAIDs
1
, o Dressler’s syndrome: pericarditis 2-4 weeks after, fever, pleural effusions, raised ESR. NSAIDs +/- steroids
o Mitral regurgitation (papillary muscle rupture) -> pansystolic murmur radiating to axillae
- Cannot use scoring systems e.g. CHA2DS2VASc if previous MI
Atrial fibrillation
- Admit for rhythm control if onset of AF <48h, haemodynamic instability (HR >150, BP <90), LOC, syncope, ongoing chest
pain or breathlessness, AF leading to acute heart failure, or reversible cause e.g. pneumonia, electrolyte imbalance
- Otherwise rate-control is 1st line:
o BB (bisoprolol, metoprolol, atenolol, sotalol), diltiazem or verapamil.
o Digoxin (only for non-paroxysmal AF if sedentary lifestyle & others not suitable)
o Follow up after 1 week
- Uncontrolled symptoms:
o Combination therapy (B-blocker, diltiazem, digoxin)
o If not controlled on combination therapy refer to be seen within 4 weeks
- Calculate CHA2DS2VASc and ORBIT score for everyone
o Offer anticoagulation if CHA2DS2VASc 2, consider for men 1 (reduces stroke risk by 2/3rd)
o Don’t withhold anticoagulation just based on age + history of falls
- DOACs 1st line: apixaban, edoxaban, rivaroxaban (eGFR >15), and dabigatran (eGFR >30)
o Warfarin 2nd line if above contraindicated
o Monitoring of warfarin:
▪ INR daily/alternate days until within therapeutic range 2-3 on 2 consecutive occasions
▪ Then twice weekly for 1-2 weeks
▪ Then weekly until at least two INR measurements are within therapeutic range
▪ Once stable, monitor at longer intervals up to once every 12 weeks
- Risk of paroxysmal AF (<7d, often <48h) = persistent (>7d) = permanent (failed CV) AF
- If paroxysmal AF is suspected and not detected on standard ECG, arrange ambulatory ECG as long as appropriate
- Consider ECHO if considering rhythm control, underlying heart disease e.g. HF or valvular disease, borderline
CHA2DS2VASc score
- Amiodarone is always initiated in secondary care. Monitoring of amiodarone requires:
o TFTs, LFTs, U&Es every 6 months and every 12 months after discontinuation
o ECG every 12 months
o CXR and regular eye checks for corneal deposits
- Amiodarone S/E: pulmonary toxicity, thyroid dysfunction, photosensitive reaction, corneal deposits, constipation,
arrhythmias, prolonged QT (interactions can occur after treatment withdrawal due to long half-life ~100 days)
Anticoagulation
- All DOACs are licensed for prevention of stroke/embolic event in non-valvular AF, treatment & prevention of DVT/PE
o Licensed for use in patients with active cancer
- All DOACs except edoxaban are licensed for prevention of embolism in elective knee/hip surgery
- Only rivaroxaban is licensed post-MI (CI if TIA)
- Apixaban for AF: 5mg BD
o 2.5mg BD if CrCl 15-29, or 2 of 3: 80, 60kg, Cr 133
- Apixaban for treatment of DVT/PE: 10mg BD for 7 days -> 5mg BD
- risk of bleeding with other anticoagulants, NSAIDs, antifungals, SSRIs, SNRIs e.g. venlafaxine
- Warfarin -> DOAC: start apixaban once INR <2
- DOAC -> warfarin: continue DOAC until INR in range
- Low bleeding risk procedure stop 24h before, high bleeding risk procedure stop 48h before
- Monitoring for DOACs: FBC, LFTs, U&Es every year
- Dabigatran 150mg BD, reduced to 110mg BD if 80y, or on concurrent tx with verapamil
- Edoxaban for AF: 60mg OD
o 30mg OD if CrCl <30, 60kg
2
, - Rivaroxaban for AF: 20mg OD
o 15mg OD if CrCl <30
- Rivaroxaban for treatment of DVT/PE: 15mg BD for 21 days -> 20mg OD
- High INR
o INR >8 + no bleeding -> stop warfarin, give PO Vit K
o INR >5 + minor bleeding -> stop warfarin, give IV Vit K
o INR 5–8 + no bleeding -> hold warfarin, restart when INR <5
- Poor anticoagulation control is TTR <65%
Antiplatelets
- Antiplatelets should not be prescribed routinely for primary prevention of CVD
- ACS: aspirin 75mg + ticagrelor 90mg BD for 12 months (if high bleeding risk -> aspirin 75mg + clopidogrel 75mg)
- Stroke/TIA/PAD: clopidogrel 75mg. 2nd line aspirin 75mg
- AF: DAPT if cannot have anticoagulation
- Co-prescribe PPI if on DAPT, 70, history of PUD, or also taking SSRI, steroids, NSAIDs
- Aspirin caution in asthma/bronchospasm. Avoid in breastfeeding.
- Clopidogrel can be less effective if given with omeprazole/esomeprazole
Hypertension
- Clinic BP
o <140/90: check BP at least every 5 years
o 140/90 to 179/119:
▪ Offer ABPM or HBPM
▪ Investigate for target organ damage
▪ Assess cardiovascular risk
o 180/120 (stage 3):
▪ Refer for same day review if papilloedema, new confusion, chest pain, new heart failure, AKI,
suspected phaeochromocytoma
▪ If not, assess for target organ damage as soon as possible
• If present, start drug treatment immediately
• If not, repeat clinic BP within 7 days or consider ABPM/HBPM and review within 7 days
- ABPM or HBPM
o <135/85: check BP at least every 5 years
o 135/85 to 149/94:
▪ Age >80 and clinic BP >150/90
• Offer lifestyle advice and consider drug treatment
▪ Age <80 with target organ damage, CVD, renal disease, diabetes or QRISK 10%
• Offer lifestyle advice and discuss starting drug treatment
▪ Age <60 with QRISK <10%
• Offer lifestyle advice and consider drug treatment
▪ Age <40: consider specialist evaluation of secondary causes
o 150/95 (stage 2):
▪ Offer lifestyle advice and offer drug treatment
▪ Age <40: consider specialist evaluation of secondary causes
- Ix for target organ damage: urine dip, urine protein:Cr, U&Es, HbA1c, lipids, ECG, fundoscopy & calculate QRISK
- Medication:
o Step 1:
▪ ACEi or ARB (if diabetic OR <55 and not AfroCarribean)
▪ CCB (if 55 OR AfroCarribean)
▪ (if HF/oedema consider thiazide-like diuretic e.g. indapamide)
o Step 2:
▪ ACEi or ARB + CCB or thiazide like diuretic
▪ CCB + ACEi or ARB or thiazide-like diuretic
o Step 3:
▪ ACEi or ARB + CCB + thiazide-like diuretic
o Step 4:
▪ Potassium 4.5 --> low dose spironolactone
▪ Potassium >4.5 --> alpha or beta blocker
o ARB preferred to ACEi in adults of AfroCarribean family origin
o Refer to secondary care if on 4 drugs and still above target
3
, - Monitoring treatment
o Use clinic BP to monitor treatment
o Measure standing and sitting BP in people with type 2 diabetes, 80+, symptoms of postural hypotension &
base target on standing BP
- BP targets
o Age <80
▪ Clinic BP <140/90
▪ ABPM <135/85
o Age 80
▪ Clinic BP <150/90
▪ ABPM <145/85
▪ Use clinical judgement in frailty or multimorbidity
o HTN + CKD + ACR 70 = target <130/80
- Monitoring of ACE inhibitors: check U&Es at baseline and 1-2 weeks after each dose change
o If eGFR <25% or Cr <30%: continue medication & recheck after 1-2 weeks
o If more than above, investigate other causes, stop other nephrotoxic drugs. If no improvement stop or reduce
dose to previously tolerated dose
o If K+ >5, investigate other causes, stop other K+ sparing diuretics and nephrotoxic drugs
▪ If K+ 5–5.9, reduce the dose and recheck after 1 week
▪ If K+ >6 stop
Heart failure
- Symptoms (breathlessness, ankle swelling, fatigue) + signs (elevated JVP, basal creps, peripheral oedema)
- NYHA classification
o I = no symptoms & no limitation of physical activity
o II = mild symptoms & slight limitation of physical activity (ordinary activity -> fatigue, palpitations, dyspnoea)
o III = moderate symptoms & marked limitation of physical activity (less than ordinary activity -> SOB, fatigue)
o IV = severe symptoms & symptoms at rest (any physical activity causes further discomfort)
- Referral
o BNP 400 – 2000: specialist assessment and echocardiogram within 6 weeks
o BNP >2000: specialist assessment and echocardiogram within 2 weeks
▪ BNP may be falsely low in BMI >35, ACEi/ARB/BB/spiro/diuretics, Afro-Caribbean
▪ BNP may be falsely raised in age >70, DM, PE, CKD, MI, hypoxia, COPD, pulmonary HTN, sepsis
o Severe heart failure NYHA class IV
o Heart failure that does not respond to treatment in primary care
o LVEF <35%
- 1st line ACEi and BB (bisoprolol, carvedilol, nebivolol)
o Start one drug at a time – ACEi preferable if diabetic or signs of fluid overload
- If symptoms not controlled, add aldosterone antagonist e.g. spironolactone (monitor K+)
- SGLT-2 inhibitors e.g. dapagliflozin for HF with reduced EF
- Loop diuretic for symptoms of fluid overload
- 3rd line treatment (specialist): cardiac resynchronisation therapy, digoxin, hydralazine + nitrate (AfroCarribean)
- Consider antiplatelet and statin
- Supervised exercise-based rehabilitation programme for those with stable HF
- Annual flu vaccine, once only pneumococcal
Lipid modification – CVD prevention
- If high risk CVD -> HbA1c and non-fasting lipid profile
- If triglycerides high -> repeat with a fasting sample
o Triglyceride 20 & not due to alcohol or poor glycaemic control -> urgent referral to specialist
o Triglyceride 10-20 -> repeat after 5d or within 2 weeks -> refer if still >10
- QRISK <10% or people <40y: motivate lifestyle changes
- Offer atorvastatin 20mg for primary prevention to:
o <85y and QRISK 10%
o Type 1 diabetics if >40y, have had diabetes for >10y, established nephropathy, presence of other CVD RFs
(without formal risk assessment). Consider in all type 1 diabetics.
- Offer atorvastatin 80mg for secondary prevention to patients with existing CVD (MI, angina, stroke, TIA, PAD)
o If CKD 3 (eGFR <60) start at 20mg
- Baseline investigations: HbA1c, lipid profile (cholesterol & triglycerides), LFTs, U&Es
o CK (only if persistent generalised unexplained muscle pain)
o TSH (only in people with symptoms of hyper/hypothyroidism)
o Do not prescribe statins if LFTs >3x ULN, pregnant, breastfeeding, CK >5x ULN on 2 readings 7 days apart
4
Chest pain referral
- Current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
- Chest pain 12-72 hours ago: refer to hospital the same-day for assessment
- Chest pain > 72 hours ago: perform full assessment with ECG and troponin to decide further management
Angina
- Constricting pain in chest/neck/arm precipitated by exertion, relieved by rest or GTN
o Typical = all 3, atypical = 2 of 3
- Acute management: GTN for symptom control. Take again after 5 min, if not better 5 min after second dose call 999
- Preventative treatment for stable angina:
o 1st line = BB or CCB (diltiazem, verapamil)
o 2nd line (if both not tolerated/contraindicated) = long-acting nitrate e.g. ISMN, nicorandil, ivabradine,
ranolazine.
o Consider aspirin 75mg (people with stroke or PAD should continue clopidogrel instead of aspirin)
o Consider ACEi if diabetic, CKD, HF, previous MI
o Offer statin
o Offer anti-HTN meds
- Uncontrolled symptoms = combination treatment:
o BB + long acting CCB e.g. amlodipine, MR nifedipine, MR felodipine
o BB + nitrate (if CCB not tolerated/contraindicated)
▪ Stop ivabradine if no improvement after 3 months and seek specialist advice
o Long acting CCB + nitrate (if BB not tolerated/contraindicated)
▪ Do not combine BB with rate-limiting CCB due to risk of bradycardia
▪ Do not combine ivabradine with a rate-limiting CCB due to risk of excessive bradycardia
- Refer if symptom control is poor on 2 drugs. Consider starting third anti-anginal while waiting specialist assessment
- Stable angina: refer to RACPC
- Consider hospital admission for unstable angina (pain at rest, pain on minimal exertion, angina progressing rapidly
despite medical treatment)
- All patients with angina should have CT coronary angiography
MI
- Acute MI -> admit via 999 but in the meantime give:
o Oxygen if sats <94% -> face mask, 5-10L, target sats 94-98%
▪ If CO2 at risk of hypercapnia -> use 28% Venturi, 4L flow rate, target sats 88-92%
o Aspirin 300mg
o Analgesia if available: GTN and/or opioid
o Do 12 lead ECG but do not delay hospital transfer
- Pain >72 hours ago, now pain-free & no complications, consider diagnosing in primary care
o ECG
o Troponin
o Refer to be seen within 2 weeks
- Lifestyle advice
o 150 min moderate intensity exercise per week, 2 sessions muscle strengthening exercise per week
o 4-5 portions (30g) of unsalted nuts/seeds per week
o Total fat intake <30%, saturated fat <7%. Diet supplementation with omega 3 NOT recommended
o 2 portions of fish per week. 5 portions fruit/veg per week
o Salt <6g/day
o Stop smoking, alcohol <14 units
- Cardiac rehabilitation programme with exercise, health education & stress management for all patients
- Secondary prevention:
o ACEi (not in pregnancy or breastfeeding)
o BB
o DAPT: aspirin + [ticagrelor or clopidogrel if high bleeding risk]
o Statin (usually atorvastatin 80mg)
- Acute MI with sx of HF and LVSD: aldosterone antagonist e.g. eplerenone should be initiated
- Annual flu vaccine
- Sexual intercourse after 4 weeks. Sildenafil can be used after 6 months (unless on nitrates/nicorandil)
- Complications:
o Pericarditis: central chest pain, worse on inspiration & lying flat, relieved by leaning forward. Pericardial
friction rub. ECG: saddle shaped ST elevation +/- PR depression. Mx: NSAIDs
1
, o Dressler’s syndrome: pericarditis 2-4 weeks after, fever, pleural effusions, raised ESR. NSAIDs +/- steroids
o Mitral regurgitation (papillary muscle rupture) -> pansystolic murmur radiating to axillae
- Cannot use scoring systems e.g. CHA2DS2VASc if previous MI
Atrial fibrillation
- Admit for rhythm control if onset of AF <48h, haemodynamic instability (HR >150, BP <90), LOC, syncope, ongoing chest
pain or breathlessness, AF leading to acute heart failure, or reversible cause e.g. pneumonia, electrolyte imbalance
- Otherwise rate-control is 1st line:
o BB (bisoprolol, metoprolol, atenolol, sotalol), diltiazem or verapamil.
o Digoxin (only for non-paroxysmal AF if sedentary lifestyle & others not suitable)
o Follow up after 1 week
- Uncontrolled symptoms:
o Combination therapy (B-blocker, diltiazem, digoxin)
o If not controlled on combination therapy refer to be seen within 4 weeks
- Calculate CHA2DS2VASc and ORBIT score for everyone
o Offer anticoagulation if CHA2DS2VASc 2, consider for men 1 (reduces stroke risk by 2/3rd)
o Don’t withhold anticoagulation just based on age + history of falls
- DOACs 1st line: apixaban, edoxaban, rivaroxaban (eGFR >15), and dabigatran (eGFR >30)
o Warfarin 2nd line if above contraindicated
o Monitoring of warfarin:
▪ INR daily/alternate days until within therapeutic range 2-3 on 2 consecutive occasions
▪ Then twice weekly for 1-2 weeks
▪ Then weekly until at least two INR measurements are within therapeutic range
▪ Once stable, monitor at longer intervals up to once every 12 weeks
- Risk of paroxysmal AF (<7d, often <48h) = persistent (>7d) = permanent (failed CV) AF
- If paroxysmal AF is suspected and not detected on standard ECG, arrange ambulatory ECG as long as appropriate
- Consider ECHO if considering rhythm control, underlying heart disease e.g. HF or valvular disease, borderline
CHA2DS2VASc score
- Amiodarone is always initiated in secondary care. Monitoring of amiodarone requires:
o TFTs, LFTs, U&Es every 6 months and every 12 months after discontinuation
o ECG every 12 months
o CXR and regular eye checks for corneal deposits
- Amiodarone S/E: pulmonary toxicity, thyroid dysfunction, photosensitive reaction, corneal deposits, constipation,
arrhythmias, prolonged QT (interactions can occur after treatment withdrawal due to long half-life ~100 days)
Anticoagulation
- All DOACs are licensed for prevention of stroke/embolic event in non-valvular AF, treatment & prevention of DVT/PE
o Licensed for use in patients with active cancer
- All DOACs except edoxaban are licensed for prevention of embolism in elective knee/hip surgery
- Only rivaroxaban is licensed post-MI (CI if TIA)
- Apixaban for AF: 5mg BD
o 2.5mg BD if CrCl 15-29, or 2 of 3: 80, 60kg, Cr 133
- Apixaban for treatment of DVT/PE: 10mg BD for 7 days -> 5mg BD
- risk of bleeding with other anticoagulants, NSAIDs, antifungals, SSRIs, SNRIs e.g. venlafaxine
- Warfarin -> DOAC: start apixaban once INR <2
- DOAC -> warfarin: continue DOAC until INR in range
- Low bleeding risk procedure stop 24h before, high bleeding risk procedure stop 48h before
- Monitoring for DOACs: FBC, LFTs, U&Es every year
- Dabigatran 150mg BD, reduced to 110mg BD if 80y, or on concurrent tx with verapamil
- Edoxaban for AF: 60mg OD
o 30mg OD if CrCl <30, 60kg
2
, - Rivaroxaban for AF: 20mg OD
o 15mg OD if CrCl <30
- Rivaroxaban for treatment of DVT/PE: 15mg BD for 21 days -> 20mg OD
- High INR
o INR >8 + no bleeding -> stop warfarin, give PO Vit K
o INR >5 + minor bleeding -> stop warfarin, give IV Vit K
o INR 5–8 + no bleeding -> hold warfarin, restart when INR <5
- Poor anticoagulation control is TTR <65%
Antiplatelets
- Antiplatelets should not be prescribed routinely for primary prevention of CVD
- ACS: aspirin 75mg + ticagrelor 90mg BD for 12 months (if high bleeding risk -> aspirin 75mg + clopidogrel 75mg)
- Stroke/TIA/PAD: clopidogrel 75mg. 2nd line aspirin 75mg
- AF: DAPT if cannot have anticoagulation
- Co-prescribe PPI if on DAPT, 70, history of PUD, or also taking SSRI, steroids, NSAIDs
- Aspirin caution in asthma/bronchospasm. Avoid in breastfeeding.
- Clopidogrel can be less effective if given with omeprazole/esomeprazole
Hypertension
- Clinic BP
o <140/90: check BP at least every 5 years
o 140/90 to 179/119:
▪ Offer ABPM or HBPM
▪ Investigate for target organ damage
▪ Assess cardiovascular risk
o 180/120 (stage 3):
▪ Refer for same day review if papilloedema, new confusion, chest pain, new heart failure, AKI,
suspected phaeochromocytoma
▪ If not, assess for target organ damage as soon as possible
• If present, start drug treatment immediately
• If not, repeat clinic BP within 7 days or consider ABPM/HBPM and review within 7 days
- ABPM or HBPM
o <135/85: check BP at least every 5 years
o 135/85 to 149/94:
▪ Age >80 and clinic BP >150/90
• Offer lifestyle advice and consider drug treatment
▪ Age <80 with target organ damage, CVD, renal disease, diabetes or QRISK 10%
• Offer lifestyle advice and discuss starting drug treatment
▪ Age <60 with QRISK <10%
• Offer lifestyle advice and consider drug treatment
▪ Age <40: consider specialist evaluation of secondary causes
o 150/95 (stage 2):
▪ Offer lifestyle advice and offer drug treatment
▪ Age <40: consider specialist evaluation of secondary causes
- Ix for target organ damage: urine dip, urine protein:Cr, U&Es, HbA1c, lipids, ECG, fundoscopy & calculate QRISK
- Medication:
o Step 1:
▪ ACEi or ARB (if diabetic OR <55 and not AfroCarribean)
▪ CCB (if 55 OR AfroCarribean)
▪ (if HF/oedema consider thiazide-like diuretic e.g. indapamide)
o Step 2:
▪ ACEi or ARB + CCB or thiazide like diuretic
▪ CCB + ACEi or ARB or thiazide-like diuretic
o Step 3:
▪ ACEi or ARB + CCB + thiazide-like diuretic
o Step 4:
▪ Potassium 4.5 --> low dose spironolactone
▪ Potassium >4.5 --> alpha or beta blocker
o ARB preferred to ACEi in adults of AfroCarribean family origin
o Refer to secondary care if on 4 drugs and still above target
3
, - Monitoring treatment
o Use clinic BP to monitor treatment
o Measure standing and sitting BP in people with type 2 diabetes, 80+, symptoms of postural hypotension &
base target on standing BP
- BP targets
o Age <80
▪ Clinic BP <140/90
▪ ABPM <135/85
o Age 80
▪ Clinic BP <150/90
▪ ABPM <145/85
▪ Use clinical judgement in frailty or multimorbidity
o HTN + CKD + ACR 70 = target <130/80
- Monitoring of ACE inhibitors: check U&Es at baseline and 1-2 weeks after each dose change
o If eGFR <25% or Cr <30%: continue medication & recheck after 1-2 weeks
o If more than above, investigate other causes, stop other nephrotoxic drugs. If no improvement stop or reduce
dose to previously tolerated dose
o If K+ >5, investigate other causes, stop other K+ sparing diuretics and nephrotoxic drugs
▪ If K+ 5–5.9, reduce the dose and recheck after 1 week
▪ If K+ >6 stop
Heart failure
- Symptoms (breathlessness, ankle swelling, fatigue) + signs (elevated JVP, basal creps, peripheral oedema)
- NYHA classification
o I = no symptoms & no limitation of physical activity
o II = mild symptoms & slight limitation of physical activity (ordinary activity -> fatigue, palpitations, dyspnoea)
o III = moderate symptoms & marked limitation of physical activity (less than ordinary activity -> SOB, fatigue)
o IV = severe symptoms & symptoms at rest (any physical activity causes further discomfort)
- Referral
o BNP 400 – 2000: specialist assessment and echocardiogram within 6 weeks
o BNP >2000: specialist assessment and echocardiogram within 2 weeks
▪ BNP may be falsely low in BMI >35, ACEi/ARB/BB/spiro/diuretics, Afro-Caribbean
▪ BNP may be falsely raised in age >70, DM, PE, CKD, MI, hypoxia, COPD, pulmonary HTN, sepsis
o Severe heart failure NYHA class IV
o Heart failure that does not respond to treatment in primary care
o LVEF <35%
- 1st line ACEi and BB (bisoprolol, carvedilol, nebivolol)
o Start one drug at a time – ACEi preferable if diabetic or signs of fluid overload
- If symptoms not controlled, add aldosterone antagonist e.g. spironolactone (monitor K+)
- SGLT-2 inhibitors e.g. dapagliflozin for HF with reduced EF
- Loop diuretic for symptoms of fluid overload
- 3rd line treatment (specialist): cardiac resynchronisation therapy, digoxin, hydralazine + nitrate (AfroCarribean)
- Consider antiplatelet and statin
- Supervised exercise-based rehabilitation programme for those with stable HF
- Annual flu vaccine, once only pneumococcal
Lipid modification – CVD prevention
- If high risk CVD -> HbA1c and non-fasting lipid profile
- If triglycerides high -> repeat with a fasting sample
o Triglyceride 20 & not due to alcohol or poor glycaemic control -> urgent referral to specialist
o Triglyceride 10-20 -> repeat after 5d or within 2 weeks -> refer if still >10
- QRISK <10% or people <40y: motivate lifestyle changes
- Offer atorvastatin 20mg for primary prevention to:
o <85y and QRISK 10%
o Type 1 diabetics if >40y, have had diabetes for >10y, established nephropathy, presence of other CVD RFs
(without formal risk assessment). Consider in all type 1 diabetics.
- Offer atorvastatin 80mg for secondary prevention to patients with existing CVD (MI, angina, stroke, TIA, PAD)
o If CKD 3 (eGFR <60) start at 20mg
- Baseline investigations: HbA1c, lipid profile (cholesterol & triglycerides), LFTs, U&Es
o CK (only if persistent generalised unexplained muscle pain)
o TSH (only in people with symptoms of hyper/hypothyroidism)
o Do not prescribe statins if LFTs >3x ULN, pregnant, breastfeeding, CK >5x ULN on 2 readings 7 days apart
4
