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Five-minute Practitioner: June 2008

Only got five minutes? Then just read these key points on: chronic heart failure, CVD risk and supraventricular tachycardias

Only got five minutes? Then just read these key points on: chronic heart failure, CVD risk and supraventricular tachycardias

Chronic heart failure

Chronic heart failure is a common syndrome of breathlessness and fatigue in the presence of LVD. Its prevalence increases with age, reaching 10% in patients >80 years. It is not in itself a definitive diagnosis, and in all patients an attempt should be made to establish the underlying aetiology.

Patients presenting with symptoms suggesting heart failure should have a full physical examination looking for signs of fluid overload, cardiac murmurs and extra sounds, and arrhythmia. A 12-lead ECG is essential.

An entirely normal ECG makes a diagnosis of significant heart failure unlikely, whereas conduction disease, such as LBBB, atrial fibrillation, ischaemia, previous infarction or left ventricular hypertrophy increase the likelihood of LV dysfunction. NTproBNP is a useful screening test.

All patients should have some form of cardiac imaging, which can establish the presence of LV dysfunction, identify clinically relevant valvular disease, and guide therapy.

Management involves fluid and salt restriction, weight control, regular exercise and advice to stop smoking.

The lowest dose of loop diuretic necessary to control symptoms should be used. ACE inhibitors or ARBs should also be prescribed. They improve symptoms and prognosis and reduce hospitalisation for heart failure. Beta-blockers such as carvedilol and bisoprolol reduce sympathetic activation and improve survival.

CVD risk

A multifactorial approach to CVD risk management is of paramount importance, along with a systematic approach to the assessment of cardiovascular risk.

Patients with established CVD, chronic kidney disease, diabetes and familial hyperlipidaemias should be excluded from risk assessment as they already have a substantial risk of CVD.

NICE recommends that initial estimation of risk should be based on a modified version of the 1991 Framingham 10-year risk equations. GPs should focus on those aged 40-74, initially using data already held in the primary care record. The guidance emphasises the importance of explaining to patients clearly their absolute, rather than relative, risk.

Patients with an estimated 10-year CVD risk of >20% need a formal risk assessment including systolic blood pressure, total cholesterol, HDL cholesterol, smoking status and the presence of LV hypertrophy.

Risk scores should be adjusted according to ethnicity, BMI and family history of premature heart disease.

Cholesterol is a key modifiable risk factor in CVD prevention with both lifestyle and drug treatment pivotal in cholesterol management. Statin therapy should be initiated if diet and lifestyle interventions are unsuccessful at lowering lipids.

SVTs

The mechanisms of cardiac arrhythmias are complex and recognising these conditions can be difficult. When an arrhythmia is suspected, a prompt ECG is vital, even if symptoms have subsided, as this may be useful for future reference, diagnosis and therapy.

AVNRT accounts for 60% of patients presenting with a narrow complex tachycardia. It occurs mainly in young adults, particularly women. Most of these patients have structurally normal hearts. However, some patients with AVNRT may have associated mitral valve disease, pericarditis, myocardial ischaemia or congenital heart anomalies.

AVRT is an accessory pathway-mediated tachycardia. The incidence of AVRT in the general population is 0.1-0.3% and it accounts for 30% of all SVTs. AVRT is twice as common in men than women and tends to present at a younger age than AVNRT. Most patients with AVRT do not have structural heart disease.

The diagnosis and management of these arrhythmias is by review of 12-lead ECG and ambulatory recordings with correlation to the clinical setting.

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