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Five-minute Practitioner: June 2007

Only got five minutes? Then just read these key points on: atrial fibrillation, cardiomyopathies, CVD management and fever in children

Only got five minutes? Then just read these key points on: atrial fibrillation, cardiomyopathies, CVD management and fever in children

Atrial fibrillation

Atrial fibrillation is the most common chronic cardiac arrhythmia. It is characterised by rapid and chaotic activation of the atria and accounts for 10-15% of all ischaemic strokes. Prevalence is higher in men and increases dramatically with age.

The assessment of patients with AF requires a full history and clinical examination in order to identify additional comorbidities and assess stroke risk. All patients who have an irregular pulse or symptoms suggestive of AF should have an ECG.

NICE recommends the use of warfarin in AF patients at high risk of stroke, and aspirin 75-300mg for low risk.

Management of AF revolves around the choice of treatments to control the ventricular rate or to achieve and maintain sinus rhythm.

Cardiomyopathies

Cardiomyopathies can present at any age. The most common presenting complaint is symptoms of heart failure. A significant proportion of individuals are asymptomatic until they present as cases of sudden cardiac death. Screening is carried out in professional sportsmen and is recommended for competitive athletes.

In primary care, the most common cardiomyopathy encountered is hypertrophic cardiomyopathy, followed by nonischaemic dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy.

Hypertrophic cardiomyopathy is considered to be the most common cause of death during sporting activities, and has an annual cardiovascular mortality of approximately 1%. Most patients with hypertrophic cardiomyopathy are asymptomatic and are diagnosed incidentally, or when screening the family of sudden cardiac death cases.

The most common symptoms are dyspnoea and chest pain. Chest pain can be exertional or related to the consumption of large meals and alcohol. Diagnosis is by two-dimensional echocardiography.

Cardiomyopathy should be suspected in patients with:

• Severe, recurrent and exertional chest pain

• Palpitations associated with dyspnoea, presyncope/syncope

• Exertional presyncope/syncope

• A family history of sudden cardiac death.

CVD management

The Nice guideline draws on the most recent evidence to update recommendations on drug therapy following MI and to underscore the importance of lifestyle advice and a comprehensive programme of cardiac rehabilitation for these patients.

Patients should be encouraged to undertake regular physical activity, gradually building up to 20-30 minutes each day, and exerting themselves to the point of slight breathlessness.

The guidance recommends at least 7g, or two to four portions of oily fish, per week. If this is not achieved within the first three months post MI, patients should be offered at least 1g daily of omega-3 supplements licensed for secondary prevention, continued for up to four years. There is clear advice against taking supplements such as beta-carotene, vitamins C and E and folic acid, for which there is no evidence of benefit and which may cause harm.

The NICE guideline recommends that all healthcare professionals caring for patients after MI should promote cardiac rehabilitation for patients irrespective of their age and comorbidity, including those with LV dysfunction who are stable.

Fever in children

Infection is the second highest cause of death in the first year of life, after congenital defects, and causes 100 deaths in England and Wales each year.

Duration and height of fever is not predictive of serious illness, except in two specific cases:

• A fever of ? 38°C in a child under three months signifies a one in 10 risk of a serious bacterial infection

• A fever for at least 5 days is part of the diagnostic criteria for Kawasaki disease.

A respiratory rate >60 breaths/min is a high-risk marker for illness in children. It is also a specific marker for dehydration and for pneumonia.

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