Stroke is the third commonest cause of adult death and the leading cause of complex disability in the UK. This article will discuss the importance of the early recognition of stroke and transient ischaemic attack and the role of primary care staff in implementing national guidelines. Practical case study examples are included.
How can we avoid a stroke crisis?
A report from a multidisciplinary alliance has made a compelling case for a coordinated planin Europe to reduce the health, social and economic burdens of stroke related to atrialfibrillation (AF). The group comprises eminent cardiologists, neurologists, a healtheconomists, hospital pharmacists, a haematologist and representatives from patientorganisations.How Can We Avoid a Stroke Crisis? has been endorsed by 17 medical and patientorganisations, including the European Primary Care Cardiovascular Society. Its aim is tohighlight to European policy makers the need to achieve earlier diagnosis and bettermanagement of AF across Europe, with the ultimate goal of reducing the risk of stroke inpatients with AF. The key points summarised in the report are shown in table 1.
Current evidence for the management and early treatment of transient ischaemic attack
Transient ischaemic attack (TIA) is an important risk factor for stroke. Early recognition of symptoms and timely secondary prevention significantly reduce stroke risk. We review current evidence and guidelines for early management and treatment of TIA, including early antiplatelet therapy, specialist review, and recognition and treatment of other risk factors. The roles of carotid artery and brain imaging are also considered.
Recognition of post-stroke depression: a chance to improve outcomes
Depression is common after a stroke. All stroke patients should have their mood assessed. A range of evidence-based interventions may be used, and guidelines should be implemented since failure to treat depression leads to poorer outcomes in rehabilitation and recovery.
Vitamin D and cardiovascular health
Vitamin D deficiency is a prevalent and important health issue that warrants vigilant systematic screening and appropriate treatment and follow-up on the part of physicians, especially those in the primary care and cardiovascular fields. Although vitamin D deficiency has traditionally been associated primarily with bone disease, it is now clear that this is a multi-organ system disease. Epidemiological studies consistently show strong associations between vitamin D deficiency and bone disease, cancer and diabetes. Additionally, epidemiological evidence links vitamin D deficiency with cardiovascular risk factors, cardiovascular disease and mortality. Conclusive evidence to show that vitamin D supplementation improves cardiovascular prognosis is currently lacking, although randomised trials are under way to address this issue. In this article we review the sources and metabolism of vitamin D, the epidemiology of vitamin D deficiency, and the available evidence linking vitamin D deficiency to cardiovascular disease; and we suggest an approach to systematic screening and to treatment of vitamin D deficiency.
Understanding the impact of statin titration: a modelling approach
Introduction: Clinical guidelines specifying target cholesterol levels may require dose titration strategies for patients who do not reach target. We describe a model that simulates cholesterol and cardiovascular risk reductions for different populations, therapies, titration steps and targets.
Looking back, looking forward: reflecting on the winter season and the demise of the PCCS
The message regarding eating less has come across loud and clear this year, but there has been plenty to worry about over the last twelve months. The demise of the Primary Care Cardiovascular Society (PCCS) has been on my mind. I was saddened to attend an Extraordinary General Meeting in January 2012, when it was decided to wind up the Society with honour due to declining funds and concern that this situation was likely to deteriorate for the foreseeable future. The closure of the PCCS is a great blow to all of us interested in promoting and improving the prevention and management of cardiovascular disease in our communities.
Atrial fibrillation and stroke: Optimising prevention and treatment
Uniquely, AF is an eminently preventable cause of stroke with a simple and highly effective treatment. AF is common and affects over 600,000 patients in England (1.2%). It is a major predisposing factor for stroke, and strokes caused by AF can be particularly severe and disabling. The annual risk of stroke is five to six times greater in AF patients, but […]
Effective management of atrial fibrillation
Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia, and has a significant impact on morbidity and mortality. Treatment is tailored to the individual. This article will review the rhythm-management strategies for patients with atrial fibrillation, and discuss the roles of secondary and tertiary care.
Management and early treatment of transient ischaemic attack (TIA)
The White Paper, Saving lives: our healthier nation (1999), set out a target to reduce the death rate from coronary heart disease and related illnesses such as stroke by 40% in the under-75s by 2010;1 recent trends indicate that this target will be met. Although the past forty years have seen a significant reduction in age-standardised stroke mortality rates, stroke still accounts for around 53,000 deaths each year in the UK, with more than 9,500 of these occurring in the under-75s.2 This article reviews how we might reduce the huge burden of stroke by improving the management of transient ischaemic attack (TIA).
What is the real role of anticoagulants in atrial fibrillation and stroke?
The majority (84%) of people with AF are over the age of 65 years. In the UK, the prevalence of AF is 7.2% for patients aged 65 and over. AF is a particularly important risk factor for stroke in the elderly. 15% of all strokes are associated with the arrhythmia, increasing to 36% in people over the age of 80. The prevalence of AF is higher in men at all ages, although the overall number of patients with AF is approximately equal between the sexes because of unequal death rates. In overall terms, approximately 50% of patients with AF are 75 or over, and over half of these are women.
Catheter and surgical ablation of cardiac arrhythmias
Catheter and surgical ablation of cardiac arrhythmias have evolved rapidly over the last 30 years. Catheter ablation of ‘simple’ atrial arrhythmias such as supraventricular tachycardias and typical atrial flutter is very successful and low-risk. Catheter ablation of atrial fibrillation (AF) is now also successful in restoring sinus rhythm for the majority of patients. The place of invasive treatment for ventricular arrhythmias in various contexts is also evolving.
Following implementation of the Department of Health’s Chapter 8 of the National Service Framework in 2005, there has been expansion of arrhythmia services in the UK. In 2010, the capacity of hospitals to treat these arrhythmias is growing rapidly, and perhaps the main barrier to patient access is the limited awareness among would-be referring physicians of which patients should be referred for such treatments. This review article outlines the ways in which arrhythmias can be treated by catheter and surgical ablation, and provides success and complication rates to help the reader determine when, and for whom, these treatments might be appropriate.
