Cardiovascular Health

Cardiovascular disease is one of the most heavily tested clinical topics in the AKT. You need to know the current NICE guidelines for hypertension, heart failure, atrial fibrillation, lipid management, and acute coronary syndromes.

Hypertension management follows NICE guideline NG136. Diagnosis requires ambulatory or home blood pressure monitoring to confirm clinic readings. Treatment thresholds: offer treatment at stage 1 (clinic BP 140/90 or higher, ABPM 135/85 or higher) if there is target organ damage, CVD risk over 10%, renal disease, or diabetes. Step 1 treatment: ACE inhibitor or ARB (CCB for Afro-Caribbean patients or those over 55). Step 2: ACE inhibitor/ARB plus CCB. Step 3: add thiazide-like diuretic. Step 4 (resistant hypertension): consider spironolactone if potassium is 4.5 or below.

Heart failure diagnosis requires NT-proBNP levels. Levels above 2000 pg/mL require urgent echocardiography within 2 weeks. Levels 400-2000 require echocardiography within 6 weeks. Treatment of heart failure with reduced ejection fraction (HFrEF) follows a stepwise approach: ACE inhibitor plus beta-blocker, add mineralocorticoid receptor antagonist (spironolactone or eplerenone), consider SGLT2 inhibitor (dapagliflozin), and consider sacubitril/valsartan to replace ACE inhibitor if still symptomatic.

Atrial fibrillation management involves rate control vs rhythm control and anticoagulation. CHA2DS2-VASc score determines stroke risk and need for anticoagulation. DOACs (apixaban, rivaroxaban, edoxaban) are first-line over warfarin. Rate control with a beta-blocker is first-line for most patients.

Lipid management uses QRISK3 for primary prevention. Offer atorvastatin 20mg if 10-year CVD risk is 10% or more. For secondary prevention, offer atorvastatin 80mg. Aim for more than 40% reduction in non-HDL cholesterol at 3 months.

Acute chest pain assessment in primary care requires rapid risk stratification. Refer immediately if suspected ACS (call 999, give aspirin 300mg). NICE guideline CG95 covers stable chest pain assessment and when to refer for investigation.