Hypertrophic obstructive cardiomyopathy is a more frequent cause of sudden death or unexpected collapse in young individuals compared to aortic stenosis.

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, nonspecific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.

Drug-induced angioedema is most frequently caused by ACE inhibitors.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Monitoring Recommendations for ACE-I Treatment

After initiating ACE-I treatment, it is recommended by NICE to monitor renal function and serum electrolytes within 1-2 weeks. However, if the patient is at a higher risk of hyperkalaemia or deteriorating renal function, such as those with Peripheral Vascular Disease, diabetes, or the elderly, it is suggested to check within 1 week. Blood pressure should be checked 4 weeks after each dose titration. After the initial monitoring, renal function and serum electrolytes only need to be checked annually unless there are abnormal blood test results or clinical judgement indicates a need for more frequent testing. By following these monitoring recommendations, healthcare professionals can ensure the safety and efficacy of ACE-I treatment for their patients.

For patients of black African or African–Caribbean origin who are taking a calcium channel blocker for hypertension and require a second medication, it is recommended to consider an angiotensin receptor blocker instead of an ACE inhibitor. An alpha-blocker is typically not a first-line option, while spironolactone may be considered as a fourth-line option. However, the 2019 update to the NICE guidelines on hypertension recommends an ARB as the preferred choice for this patient population.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Liver Function and Statin Therapy

Liver function should be assessed before starting statin therapy. If liver transaminases are three times the upper limit of normal, statins should not be initiated. However, if the liver enzymes are elevated but less than three times the upper limit of normal, statin therapy can be used. It is important to repeat liver function tests within the first three months of treatment and then at 12 months, as well as if a dose increase is made or if clinically indicated.

In the case of a modest ALT elevation due to fatty deposition in the liver, statin therapy can still be beneficial for primary prevention, especially if the patient’s Qrisk2 score is over 10%. Mild derangement in liver function is not uncommon in overweight type 2 diabetics. The patient can be treated with the usual NICE-guided primary prevention dose of atorvastatin, which is 20 mg nocte. A higher dose or alternative statin may be required in the future, depending on the patient’s response to the initial treatment and lifestyle modifications. The slight ALT rise doesn’t necessarily require a lower statin dose.

Thromboprophylaxis for High Risk Stroke Patients

This patient is at high risk for future stroke and requires anticoagulation with warfarin. To assess the risk of bleeding and stroke, it is important to calculate the HASBLED and CHADS-VASc scores. The CHADS-VASc score takes into account factors such as congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, and sex. If the score is 1 or higher, oral anticoagulation should be considered. If the score is 0, no anticoagulation is needed. If the score is 1 but the only point is for female gender, it is treated as a score of 0. In this case, the patient’s CHADS-VASc score is 2, indicating a need for anticoagulation. The target range for INR is 2-3, with a target INR of 2.5.

Cardioversion for Atrial Fibrillation: NICE Guidelines and Considerations

The National Institute for Health and Care Excellence (NICE) recommends referral to a cardiologist for rhythm-control treatment (cardioversion) in certain cases of atrial fibrillation. These include atrial fibrillation with a reversible cause, heart failure primarily caused or worsened by atrial fibrillation, and new-onset atrial fibrillation. If onset is known to be within 48 hours, referral to an acute medical unit is recommended for immediate cardioversion without anticoagulation treatment. Pharmacological cardioversion is often used as a first-line therapy, with electrical cardioversion reserved for non-responders. However, cardioversion may be less successful or not recommended in cases of long-standing atrial fibrillation, significant valve problems, cardiomegaly, or multiple recurrences of atrial fibrillation.

Monitoring Requirements for Statin Treatment

It is important to monitor patients who are undergoing statin treatment. Even if their liver function tests are normal at the beginning, they should be repeated after three months. At this point, a lipid profile should also be checked to see if the treatment targets have been achieved in terms of non-HDL cholesterol reduction. After 12 months, liver function should be checked again. If it remains normal throughout, there is no need for routine rechecking unless clinically indicated or if the statin dosage is increased. In such cases, liver function should be checked again after three months and after 12 months of the dose change.

Understanding Prognostic Factors in Aortic Stenosis

Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to limited blood flow and various symptoms such as dyspnea, angina, and syncope. While patients may be asymptomatic for years, the prognosis for symptomatic aortic stenosis is poor, with a 2-year survival rate of only 50%. Sudden deaths can occur due to heart failure or other complications.

Valvular calcification and fibrosis are the primary causes of aortic stenosis, and the presence of calcification doesn’t have a direct impact on prognosis. However, mixed aortic valve disease, which includes aortic regurgitation, can increase mortality rates, particularly in severe cases.

Left ventricular failure is a significant prognostic factor in aortic stenosis, indicating late-stage hypertrophy and fibrosis. Patients with left ventricular failure have a poor prognosis both before and after surgery. Hypertension can also impact left ventricular remodelling and accelerate the progression of aortic stenosis, but it is not as significant a prognostic factor as left ventricular failure.

Electrocardiogram (ECG) changes, such as left ventricular hypertrophy, are common in patients with aortic stenosis but are not directly correlated with mortality risk. Understanding these prognostic factors can help healthcare providers better manage and treat patients with aortic stenosis.

This man is experiencing heart failure due to ischaemic heart disease, which is a leading cause of death among men in the UK. Beta-blockers are the only medication proven to reduce all-cause mortality in patients with heart failure with reduced ejection fraction, and they can also help control hypertension. However, before starting treatment, his blood pressure and pulse should be checked to ensure that he is not at risk of bradycardia or hypotension. Spironolactone is not recommended for improving mortality in heart failure patients, but it can be used to treat hypertension and oedema. U&Es should be monitored regularly to avoid renal function deterioration and hyperkalaemia. Amlodipine and furosemide have not been shown to improve mortality in heart failure patients, but they can be used to control hypertension and oedema, respectively. U&Es should also be monitored regularly when using these medications. Ramipril has been shown to reduce hospital admissions in heart failure patients, but it can impair renal function and cause hyperkalaemia. U&Es should be checked regularly, and the medication should not be initiated if the patient’s potassium level is too high. Patients should also be advised to stop taking ramipril during diarrhoea or vomiting illnesses to avoid dehydration and acute kidney injury.