Clinical articles

Echocardiography is a commonly used diagnostic tool in assessing cardiac disease. The advent of hand-held ultrasound devices means useful information on cardiac cavity size, ventricular wall thickness and function, or apparent valvular pathology can now be obtained by general practitioners after adequate training. This will be particularly useful in the care of patients with suspected heart failure, left ventricular hypertrophy, a cardiac murmur or atrial fibrillation. It will reduce the number of patients needing referrals and the waiting times for hospital echocardiography services. It is limited by the technical specifications of the equipment and operators expertise.

A survey on cardiovascular education was sent out to over 1,800 general practitioners by the Primary Care Cardiovascular Society. This generated 304 replies. Of those responding, the majority indicated they would be interested in post-graduate education in cardiovascular medicine. Most would prefer a simple distance-learning course covering the 30 compulsory hours of postgraduate education required every year. Some would be interested in a more demanding course to achieve GPSI status. The majority did not like the current option of clinical assistant work in a hospital out-patients’ department but would attend such a department for education. There were differing views on who should pay for the course.

A systematic approach to the identification and treatment of high-risk coronary heart disease (CHD) patients has been adopted in the UK health care system.

Historically, the approach towards dementia associated with vascular disease has been to manage risk factors. Recent findings also suggest that symptomatic treatment is a realistic option, and cardiologists should be aware of treatments that are, or may soon be, available for their patients. Here, agents that have been evaluated for the symptomatic treatment of vascular dementia (VaD) are reviewed. In particular, the role of cholinesterase inhibitors is discussed. These agents are commonly used worldwide to treat the symptoms of Alzheimer’s disease (AD). Since most patients with VaD have concomitant AD, cholinesterase inhibitors may provide some benefits in these patients. In addition, these agents have demonstrated some efficacy in patients with possible or probable VaD.

Vascular disease is the most common treatable cause of dementia. Contemporary epidemiological models suggest that in developed Western societies, vascular disease alone accounts for about 15% of all dementia. In association with Alzheimer’s disease, however, it is suspected to be involved in at least 50% of all dementia. Recent research points to shared risk factors in vascular dementia and Alzheimer’s disease, and common pathogenetic processes are likely.
The exact criteria required for a diagnosis of vascular dementia remain imprecise and poorly developed. Advances in brain structural and functional imaging provide the best prospects for improvement in vascular dementia diagnosis.
Here we set out the major processes that impinge upon the health of neurones and may contribute to vascular dementia. Clinical trials of interventions that might slow progression of cognitive impairment to vascular dementia are fully justified and are likely to improve the care of many old people at particular risk of dementia.

Stroke, cognitive impairment and dementia are well-established complications of long-standing hypertension. There is a considerable time lag, usually several decades, between the onset of hypertension and the occurrence of these complications. Although antihypertensive treatment has been shown to decrease the risk of a first stroke, little evidence is available on the effects of antihypertensive treatment on the incidence of recurrent cerebrovascular events, cognitive impairment and dementia. The results of recent studies addressing this issue are discussed, along with directions for future research.

Vascular dementia (VaD) and Alzheimer”s disease (AD) are often described as distinct entities. Recent literature suggests that they may be part of a continuum, where pure VaD is quite rare, Alzheimer”s disease is only 40% of the total and AD with cerebrovascular disease makes up the majority of cases that present to memory clinics. This relationship between VaD and AD is highlighted by their common risk factors – especially cardiovascular. Pure VaD is a heterogeneous entity, now separated clinically and radiologically into cortical, subcortical and strategic infarct subtypes. The treatment of VaD includes the primary and secondary prevention of cardiovascular and cerebrovascular disease; and early signs of a dementia may not always involve memory loss. This can lead to late presentations of patients when the more obvious signs and symptoms occur. Consequently, dementia services should work more closely with cardiology and stroke services in order to detect early cases of VaD. This will be increasingly important as new treatments become available.

Achieving good glycaemic control is an important part of the treatment strategy to minimise vascular complications in diabetes. An expanding range of differently acting oral antidiabetic agents provides new choices for type 2 patients. This review considers the attributes and limitations of these agents, and their positioning in the treatment process.

My approach to assessing CHD risk

There are now well-recognised guidelines which state that when reducing someone’s risk of cardiovascular disease the decision to start medication depends on the patient’s absolute risk of coronary heart disease, as opposed to their relative risk, which should be determined using multiple risk factors.
More than 29 cardiovascular risk tools are available to calculate a patient’s absolute risk of cardiovascular disease. Choosing which risk tool to use can be difficult. This article gives a description of the differences between cardiovascular risk tools. It also discusses some of the problems and benefits of risk tools in general and examines the differences between absolute and relative risk.