Peripheral vascular disease is part of a common, widespread, atheromatous process that affects all arterial territories – the carotid, coronary, aortic, sacral and renal arteries – although it may occur in isolation. Claudication is a prognostically important condition. It increases cardiovascular morbidity and mortality. Smoking is the single most important risk factor for peripheral vascular disease, increasing the risk in a 'dose-related' way by at least threefold. The majority of patients with claudication either are smokers or have smoked. Exercise, combined with treatment of all risk factors, is very helpful in improving symptoms of claudication. The pathology, risk factors and principles of management of peripheral arterial disease are similar to those for coronary heart disease. Patients with a variety of leg symptoms and cardiovascular risk factors should be assessed for peripheral arterial disease, because only a minority of patients with peripheral arterial disease present with typical claudication.

The primary care team has an integral role in the risk assessment of patients undergoing non-cardiac surgery. The risks of non-cardiac surgery are most frequently due to coronary artery disease and impaired cardiac function, as well as other medical conditions. Perioperative risks can be eliminated or reduced if they are predicted pre-operatively and appropriate measures taken. The aim of risk assessment is to prevent or reduce peri-operative risk. Some risk factors may be correctable. Peri-operative risk depends on the: type of procedure to be performed; patient's risk profile; and experience and quality of the medical team and hospital facilities. A thorough clinical history and examination is important, and provides a fairly accurate estimation of peri-operative risk. All patients with known or suspected heart disease should be evaluated for the presence of heart failure, coronary artery disease, arrhythmia and previous myocardial infarction.

Cardiovascular disease management in primary care. The patient's responsibilities in the NHS and around the world. History. Examination. Hypertension. Heart Failure. Angina. Myocardial infarction and other acute coronary syndromes. Claudication and peripheral vascular disease. Valve disease. Arrhythmias. Coronary heart disease in women. Heart disease in pregnancy. Sexual problems in men with cardiac conditions. Congenital heart disease. Heart disease in the elderly. Perioperative risk assessment in cardiac patients. Cardiac tests and procedures.

Cardiac tests are increasingly being performed in primary care because a larger proportion of patients with cardiovascular disorders are being diagnosed, treated and monitored by primary care clinicians. Patients may often prefer to ask their general practitioner (GP) about a cardiac test, rather than ask the hospital specialist. GPs have open access at their local hospital for non-invasive cardiac tests apart from magnetic resonance imaging and computerised tomographic scanning. The cost implications of an investigation and the effects that the test and its result may have on the general well-being and psychological state of the patient should also be considered before requesting the test. Primary care clinicians need to be able to explain to patients why the test has been requested, how the test helps in their management, what it involves and what the implications are. Echocardiography provides more accurate information about cardiac chamber dimensions and wall thickness without these potential interpretational problems and without any radiological risks.

Background Data are scarce about short‐term right ventricular changes in pulmonary hypertension. Two‐dimensional knowledge‐based reconstruction of the right ventricle with 2D echocardiography (2 DKBR ) has been shown to be a valid alternative to Cardiac MRI . Patients and Methods In this longitudinal study 25 pulmonary hypertension patients underwent 2 DKBR of the right ventricle, assessment of NT ‐pro BNP levels and functional class at baseline and after a mean follow‐up of 6.1 months. Patients were followed up clinically for a further mean of 8.2 months. The majority of patients had connective tissue disease ( CTD ) associated pulmonary arterial hypertension (n=15) or chronic thromboembolic pulmonary hypertension ( CTEPH ; n=6). A total of 15 patients underwent an intervention, either new targeted therapy, escalation of targeted therapy or pulmonary endarterectomy. A total of 10 clinically stable patients were routinely followed up without any change in therapy. Results There were significant improvements in the right ventricular end‐diastolic volume index (111±29 mL/m² vs 100±36 mL/m²; P =.038), end‐systolic volume index (72±23 mL/m² vs 61±25 mL/m²; P =.001), and ejection fraction (35±10% vs 40±9%; P =.030). Changes in NT ‐pro BNP levels correlated strongest with changes in end‐systolic volume index ( r =−.77; P =<.0001). Four patients experienced clinical worsening during extended follow‐up, dilatation of the right ventricle was associated with clinical worsening. Conclusion In a CTD and CTEPH dominated patient population significant reverse remodeling and improvement of ejection fraction occurred despite a short follow‐up and was paralleled by significant changes in NT ‐pro BNP levels. Further right ventricular dilatation was associated with worse clinical outcome. 2 DKBR is a feasible substitute for Cardiac MRI to follow‐up right ventricular indices in pulmonary hypertension.

Our current understanding of the pathophysiology of pulmonary vascular disease is incomplete, since information about alterations of the pulmonary vasculature in pulmonary arterial hypertension (PAH) is primarily provided by autopsy or tissue specimens. The aim of this study was to compare the distal pulmonary vasculature of <2 mm in diameter in Systemic Sclerosis (SSc) patients with (n = 17) and without (n = 5) associated PAH using Optical Coherence Tomography during Right Heart catheterization. SSc-PAH patients showed significant thickening of Intima Media Thickening Area compared to patients without PAH (27 +/− 5.8% vs. 21 +/− 1.4%, p = 0.024). A good haemodynamic response to previous targeted PAH treatment was associated with a significantly greater number of small pulmonary artery side branches <300 μm per cm vessel (3.8 +/− 1.1 vs. 1.8 +/− 1.1; p = 0.010) and not associated with Intima Media thickening Area (26 +/− 5.4% vs. 28 +/− 6.7%; p = 0.6). Unexpected evidence of pulmonary artery thrombus formation was found in 19% of SSc-PAH patients. This is the first in-vivo study demonstrating a direct link between a structural abnormality of pulmonary arteries and a response to targeted treatment in PAH. Intravascular imaging may identify subgroups that may benefit from anticoagulation.

Background Portopulmonary hypertension (PoPH) is a rare condition associated with poor survival, and the effect of modern therapies that target pulmonary arterial hypertension (PAH) on long-term outcome is unknown. This study investigated the baseline characteristics and survival in the cohort of patients diagnosed with PoPH in the United Kingdom National Pulmonary Hypertension Service. Methods A retrospective review was conducted of all incident treatment-naïve patients with PoPH within the United Kingdom national registry diagnosed between January 2001 and December 2010. Results Patients with PoPH (n = 110) had survival rates of 85%, 60%, and 35% at 1, 3, and 5 years. The prevalence of PoPH was 0.85 cases/1 million. Mean age at diagnosis was 53 ± 12 years, with a balanced distribution in gender. Alcohol (n = 57) and hepatitis C (n = 10) were the most common causes of portal hypertension. Phosphodiesterase V inhibitors were the most frequently used targeted therapy, in 63.6% (n = 70) of patients, endothelin receptor antagonists were used in 10% (n = 11) and prostacyclin analogs in 12.7% (n = 14). Univariate and multivariate analysis of baseline characteristics did not demonstrate a significant influence of severity of portal hypertension or liver cirrhosis, World Health Organization Functional Class, cardiopulmonary hemodynamics, or year of diagnosis on survival. Conclusions Survival of patients with PoPH remains poor despite targeted therapy and worse than patients with idiopathic PAH. The benefit of PAH therapies in PoPH on long-term morbidity and mortality outcomes needs further consideration and study.

Pulmonary arterial hypertension (PAH) is a severe complication of connective tissue diseases (CTDs). This study aimed to investigate the clinical and hemodynamic characteristics and survival of anti–U1 RNP–positive patients with CTD‐associated PAH, with a focus on systemic sclerosis (SSc)–associated PAH.