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NHS Health Checks Clinical Update Michaela Nuttall RGN MSc Director, Smart Health Solutions Founder, Learn With Nurses Clinical Advisor CVD Prevention Progamme OHID Chair, Health Care Committee HEART UK Member, Nurses Working Party and Guidelines & Information Working Party, British and Irish Hypertension Society Associate in Nursing, C3 Collaborating for Health Trustee, PoTS UK @thisismichaelaSocial Media Very happy for screen shots • @thisismichaela • @LWNurses • #Learnwithnurses Feel free to tweet/Insta your experience of our training course today….Plan National Guidance / Competencies Overall refresher You chose clinical topicsNHS Health Check Competencies1. Programme knowledge • What is it for?What are we trying to prevent? Inflammation Genes Risk FactorsWe weren’t designed to live this long….Not to take in tobaccoGather nuts and berriesMove around following seasonsUK today….The future….https://www.kingsfund.org.uk/blog/2022/10/tackling-cardiovascular-disease-why-urgencyStandardised mortality ratios (SMR) for heart disease and stroke in South Asians and African Caribbeans compared to Europeans, age 20–69, from 1989–92. Nish Chaturvedi Heart 2003;89:681-686 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.https://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_united_kingdom.pdfhttps://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for- england/2021/health-survey-for-england-2021-data-tablesObesityNew data due soon Blood tests Before the check On the day with POCT • Random • Random • TC, HDL, Ratio • TC, HDL, Ratio • HBa1c • HBa1c • U & E • U & ETop 3Understanding blood pressure Across the world THE No. 1 • contributing risk factor for global death is raised blood pressure – causing strokes, heart attacks and other cardiovascular complications 10 MILLION+ • lives are lost each year needlessly due to raised blood pressure ONLY HALF • of people with high blood pressure, know itWhy high blood pressure matters 31What is Blood Pressure? Heart Arteries Arterioles (Cardiac (Blood (Peripheral output) pressure) resistance)• Systolic (the top number) • Diastolic (the bottom number) 120/70mmHgAfterload??? …is the pressure that the heart must work against to eject blood during systole (ventricular contraction)????? The Circulato ry SystemWe weren’t designed to live this long….How is BP maintained…. (easy peasy) Baroreceptors • Help the body to adjust to being upright • Keeping us functioning • Stops gravity from pulling fluid into our legs • Keeps us consciousAutonomic nervous system Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Increase cardiac output CO =Stroke volume x Heart rate Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Produce Aldosterone. Hormone helps to maintain the body’s salt and water levels Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous system Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.http://high-blood-pressure-symptoms.com/page/2https://www.nice.org.uk/guidance/ng136https://www.nice.org.uk/guidance/ng136Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.https://www.nice.org.uk/guidance/ng136Reduce the amount of calcium entering cells of the heart and arterial walls. - less strong contractions. Reduces afterload. Myocardial oxygen demand decreases. https://www.nice.org.uk/guidance/ng136Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.https://www.nice.org.uk/guidance/ng136Autonomic nervous syst me renin Copyright ©2001 BMJ Publishing Group Ltd.Lifestyle and effects on Blood Pressure Modifications Recommendation Approximate SBP Reduction Reduce weight Maintain normal body w2ight 3-20 mm Hg (BMI of 18.5-24.9 kg/m ) Adopt DASH diet Rich in fruit, vegetables and low-fat dairy; reduced saturated and total fat 8-14 mm Hg content Reduce dietary <100 mmol (2.4g)/day 2-8 mm Hg sodium Increase physical Aerobic activity >30 min/day most 4-9 mmHg activity days of the week Moderate alcohol Men: < 2 drinks/day 2-4 mm Hg consumption Women: < 1 drink/day Chobanian AV et al., JAMA 2003; 289: 2560-2572. Blumenthal JA et al., Arch Intern Med. 2000; 160: 1947-1958Understanding CKDPrevalence of CKD stage 3–5 (coded and uncoded), by ethnic group in all adults (aged ≥18 years) in Lambeth DataNet. Mariam Molokhia et al. Br J Gen Pract 2020;70:e785-e792 ©2020 by British Journal of General Practice Understanding CKD • Kidney function • What and how does the kidney go wrong? • How is it diagnosed • How does CKD impact on kidney function?NICE Kidneys do lots of things 1. Balance levels of salt and water 2. Excrete waste from the blood 3. Control blood pressure 4. Make strong bones 5. Boost production of red blood cells Renal Vein Renal Artery Ureter What makes our kidneys sad… CVD Diabetes Structural renal tract disease, renal calculi or prostatic hypertrophy Lupus erythematosus / HIV Hypertension Family history of stage 5 CKD or hereditary kidney disease Toxins Long-term NSAIDs Renal Vein Renal Artery UreterNephron (we’ve got lots and lots)Or….HypertensionHypertensionHypertension Less blood/oxygen to the nephronsDiabetesDiabetesDiabetes Increase pressure, damage those precious nephrons and hyperfiltrationLow eGFR Damage to those precious nephrons Renal Vein Renal Artery Ureter Unhappy kidney We can test for an unhappy kidneyeGFR U & E Test Levels Urea Kidney Function 2.0-6.6 mmol/’s Dehydration Sodium Raised – could indicate 135-147mmol/l dehydration, uncontrolled diabetes, Low - secondary to diuretics Heart Failure Potassium Raised - could be due to 3.4-5.6 mmol/l deterioration in Kidney Function or medication eg. ACE inhibitors Low - secondary to medication, excessive sweating, D & V Heart Failure Creatinine If blood sample taken fasting, advise Normal Range patient to drink water normally Men Advise patient not to eat meat for 12 hours prior to eGFR blood test 75-125 micromol/L By-product of muscle metabolism that is Women excreted unchanged by the kidneys 60-100 micromol/L Increase can be marker of kidney damage Can be used to calculate eGFR eGFR • Estimated on: serum Creatinine level, age, sex, and race • It is only an estimate. A significant error is possible. eGFR is most likely to be inaccurate in people at extremes of body type, for example malnourished, amputees, etc. • It is not valid in pregnant women or in children eGFR 2 If eGFR in the first test t <60 ml/min/1.73 m repeat within 14 days (exclude AKI) • To identify progression, take at least 3 eGFRs over at least 90 days • Send urine for albumin:creatinine ratio (ACR)• Albumin is a healthy protein in the bloodstream • Impaired kidneys allow albumin to leak into urine • The creatinine is a waste product that is excreted by the kidney • Impaired kidneys means some creatinine is not filtered so less in the urine. • Needs to be an early morning sample – so it’s concentrated.NICE Impact of CKD on: • Balance levels of salt and water • Excrete waste from the blood • Control blood pressure • Make strong bones • Boost production of red blood cells Impact of CKD on: Balance levels of salt and water They respond to two hormones – Antidiuretic hormone and aldosterone – which affect the reabsorption of water back Therefore, we monitor into the body. This maintains healthy plasma levels of salt, sodium and potassium particularly sodium and potassium Impact of CKD on: Excrete waste from the blood Therefore, we monitor eGFR and ACR Impact of CKD on: Control blood pressure We measure and control blood pressure Impact of CKD on: Make strong bones So, we check calcium, phosphate and parathyroid hormone levels Impact of CKD on: Boost production of red blood cells So, we check for anaemia, FBC Address makes our kidneys sad… CVD Diabetes Structural renal tract disease, renal calculi or prostatic hypertrophy Lupus erythematosus Hypertension Family history of stage 5 CKD or hereditary kidney disease Toxins Long-term NSAIDs When to look for CKD? • weight loss or poor appetite • swollen ankles, feet or hands • Shortness of breath • tiredness • blood in urine • peeing more than usual, particularly at night In summary Kidneys are precious They have lots of functions If we don’t look after them, they wont function as wellCholesterol and dietWhat about coconut oil? Across the world • In 2008, 39% of adults around the world had high total cholesterol • High cholesterol causes 4.4 million deaths every year, or 7.8% of all deaths. What is cholesterol? substance which is mainly produced by the body itself - Vital to all cells; • building block in cell membranes • starting material for bile acids • starting material for certain hormones and vitamin D High blood cholesterol increases the risk of atherosclerotic cardiovascular disease We need fat in our diet • An important source of food energy (38 kJ/g, 9 Kcal/g) • Provides and enables the absorption of fat soluble vitamins (A, D, E & K) • Provides the essential fatty acids • Palatability – mouth-feel (fat globules) and carries flavours • Structural lipids (58% body weight) – important in cellular membranes (e.g. brain) • Protects and cushions delicate organs • Substrate for hormone and prostaglandin production • Subcutaneous fat reduces loss of body heat (very important in newborns) Saturated fat guidelines • men should not eat more than 30g of saturated fat a day • women should not eat more than 20g of saturated fat a day • children should have less https://www.nhs.uk/live-well/eat-well/different-fats- nutritionImagine 2 small packs of these = 10g sat fat 2 slices 9 11 cookies 3 doughnuts squares 2 2 slices 5½ slices 4 fingers 5½ 9 biscuits rashers Foods with less than 10.8g saturated fatty acid – found in 20g butter 2 slices 9 11 cookies 3 doughnuts 2 slices squares 2 slices 5½ slices 4 fingers 5½ 9 biscuits rashers HEARTUK.org.uk 6 cholesterol busting foods! • Foods rich in unsaturated fats • Fruit and veg • Oats and barley • Nuts • Foods with added plant sterols and plant stanols • Soya foodsDifferent types of fatty acidsDifferent types of fatty acids Hydrogenated mono and diglycerides of fatty acids Insoluble vs. soluble fibre Insoluble fibre Soluble fibre • This is the fibre that the body can't digest and so it passes • This fibre can be partially digested and through the gut helping other food and waste products may help to reduce the amount of move through the gut more easily. It helps keep bowels cholesterol in the blood healthy and stop constipation. Foods rich in this sort of fibre are more bulky and so help make us feel full, which • Particularly good sources of soluble means we are less likely to eat too much fibre include oats and pulses such as beans and lentils. • Wholegrain bread, brown rice, wholegrain breakfast cereals and fruit and vegetables all contain this type of fibre. Indicated cardio- protective effects of fish omega-3 REDUCES TRIGLYCERIDES REDUCES BLOOD PRESSURE INHIBITS PLATELETS IMPROVES ENDOTHELIAL FUNCTION REDUCES PLAQUE ANTI- BLOOD STRUCTURE ARRHYTHMIC CLOTTING Foods proven to lower cholesterol Plant sterols/stanols are the most effective food components proven to lower LDL-cholesterol Plant sterols/stanolsoya drink Oat Sunflower oil Almonds Olive Oily s oil fish -0% -1% -4% -3% -6% -5% - 10% Plant sterols and plant stanols are natural components of the human diet Major sources of plant sterols and plant stanols: 2 • Fat and oils • Cereals • Fruits and vegetables • Nuts Average daily plant sterol and Daily consumption of 2g of plant stanols intake of adults plant sterols/stanols can effectively lower TC and 150 - 400mg/day 1. 2019 ESC/EAS GuidelineLDL-C levels by 7 - 10% inslipidaemias European Heart Journal (2020) 41, 111-188 2 .Gylling H, Plat J, Turley S et al; 2014; 232(2): 346–humans So1,2ty Consensus Panel on Phytosterols. Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis Quantity of regular foods required to provide 2g plant sterols and plant stanols • To get the optimal amount of plant sterols and plant stanols from regular foods would be extremely difficult • Plant sterol and plant stanols enriched foods facilitate the consumption of the recommended intake of 2g of plant sterols/day. Normen L, Johnsson M, Andersson H, van Gameran Y, Dutta P. Plant sterols in vegetables and fruits commonly consumed in Sweden. Eur J Nutr 1999;38:84-89. Normen L, Bryngelsson S, JohWeihrauch JL, Gardner JM. Sterol content of foods of plant origin. J Am Diet Assoc 1978;73(1):39-47.and in the Netherlands. J Food Comp Analysis 2002;15(6):693-704. Plant Stanol Ester - How does it work? HOW DO THEY WORK? •Plant stanols structurally resemble cholesterol, allowing them to interfere with normal cholesterol absorption in the small Plant stanol ester lowers both total cholesterol and LDL-C levels by partly intestine inhibiting the absorption of both biliary and dietary cholesterol in the small intestine (HDL-C concentrations are not affected) – to allow the plant stanols to work optimally, they should be consumed with a meal. 24–26 Plant stanol ester Without plant stanol reduces the absorption Cholesterol Plant stanol ester estthe cholesterol of of the cholesterol and in the digestive lowers the blood total tract is absorbed and LDL cholesterol to the body. 50 20 levels. % % of the of the cholesterol is cholesterol absorbed is absorbed 50 80 % % Plant stanol ester has been shown to lower cholesterol. High cholesterol is a risk factor in the development of coronary of the cholesterol is excretof the cholesterol is excreted heart disease. A daily intake of 1.5–2.4g of plant stanols has been shown to lower cholesterol by 7–10% in 2–3 weeks, 22 and this effect is sustained as long as the recommended intake is achieved daily. 23 The cholesterol-lowering effect of the plant stanols have been demonstrated in over 80 published clinical studies 24. Nissinen M et al. Am J Physiol Gastrointest Liver Physiol 2002; G1009–G1015. 25. Gylling H et al. European Atherosclerosis Society Consensus PanelPhytosterols. Atherosclerosis 2014; 232(2): 346–360. 26. Musa-Veloso K et al. Prostaglandins Leukot Essent Fatty Acids 20185(1): 9–28. 24. Gylling H, Plat J, Turley S et al; European Atherosclerosis Society Consensus Panel on Phytosterols. Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis 2014; 232(2): 346–360. 57. De Jong A, Plat J, Lütjohann D et al. Effects of long-term plant sterol or stanol ester consumption on lipid and lipoprotein metabolism in subjects on statin treatment. Br J Nutr 2008; 100: 937–941. 65. Blair SN, Capuzzi DM, Gottlieb SO et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol 2000; 86: 46–52 A dietary portfolio effectively reduces LDL- cholesterol levels Week 0 Week 2 Week 4 ) 0 g a -5 c -8.5% % -10 l Control diet e -15 s Control diet + statin o -20 Dietary portfolio h L -25 L -29.6%* -30 -35 -33.3%* 34 adults 4 week interventions # Dietary portfolio = plant sterols, soya protein, viscous fibre, almonds * Significantly different from control (low saturated fat diet) Jenkins et al. AJCN 2005What about coconut oil? Myth: Its good for heart health Fact: Coconut oil is solid at room temperature so there should be no surprise that it is really high in saturated fat - largely lauric and myristic acids. Both these fats increase your LDL cholesterol. Some have suggested that because lauric acid also raises HDL cholesterol it might have health benefits. However, the small increase in HDL-cholesterol is far outweighed by the negative increase in LDL cholesterol. https://www.heartuk.org.uk/news/latest/post/16-heart-uk-says-bbc-coconut-oil-claim-not-to-be-trusted In summary • Cholesterol can be lowered through diet modifications • Replace saturated fats with healthier unsaturated fats • Increase the intake of dietary fibre through eating more fruit/veg/fibre/oats etc • Add plant stanols and plant sterols to your diet • Thank youUnderstanding AF AF across the world • A total of 3.046 million new cases of atrial fibrillation worldwide were registered in the database during 2017. • The estimated incidence rate for 2017 (403/millions inhabitants) was 31% higher than the corresponding incidence in 1997. • The worldwide prevalence of atrial fibrillation is 37,574 million cases (0.51% of worldwide population), increased also by 33% during the last 20 years. The highest burden is seen in countries with high socio-demographic index, though the largest recent increased occurred in middle socio-demographic index countries. • Future projections suggest that absolute atrial fibrillation burden may increase by >60% in 2050. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge, 2020 The devastation of AF related strokes • FIVE times more likely to have a stroke • TWICE as likely to die prematurely • Half of those with AF related stroke will not survive beyond 12 months • Those that do will suffer increased disability compared to those who suffer non AF related strokes Prevalence of AF Increases with Age • The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50–59 years to almost 9% at age 80–89 years 12 Women 11. Men ATRIAstudy 10. 1 10 3 9.1 e 8 7.3 7.2 n a 6 e 5.0 5.0 P 4 3.4 3.0 1.7 1.7 2 0.2 0.4 0.9 1.0 0.1 0 <55 55–59 60–64 65–69 70–74 75–79 80–84 >85 Age Analysis of adults aged ≥20 years, who were enrolled in a large health maintenance organisation in California and who had AF diagnosed between July 1, 1996, and December 31, 1997; AF=atrial fibrillation; ATRIA=AnTicoagulation and Risk Factors In Atrial Fibrillation Go A, et al. JAMA 2001 ;285(18): 2370–5 Variation There is huge geographic variation in prevalence across the country depending on the demographic profile. At a GP level, this can mean prevalence ranges anywhere from 0.009% to 27.5%. Risk of Mortality with AF Framingham Age 55–74 years Age 75–94 years 80 80 Men AF Log rank 42.90 (men) Log rank 51.44 (men) (n=53) n 70 70.93 (women) 70 101.51 (women) Women AF d % 60 60 (n=47) e ( 50 50 Men no AF d u c w 40 40 (n=6999) j l 30 30 Women no AF u f 20 20 (n=8307) S 10 10 0 0 0 1 2 3 4 5 6 7 8 9 10 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Years of follow up Years of follow up  AF approximately doubles the risk of mortality in both younger and older patients 1  Two-thirds of deaths in AF patients can be attributed to CV 2 causes  Risk of death is similar for men and women with AF 3 1. Benjamin EJ, et al. Circulation 1998; 98: 946–52; 2. Lévy S, et al. Circulation 1999; 99: 3028–35; 3. Stewart S, et al. Am J Med 2002; 113: 359–64Where are you going to look for AF?UNDERSTANDING ATRIAL FIBRILLATION The Definition of AF “Atrial fibrillation is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation” NICE. Atrial fibrillation. The management of atrial fibrillation, June 2006. AF and Pre-existing CV Disease • People who develop AF usually are elderly • AF is often a manifestation of underlying cardiac disease, such as: • Hypertension (especially if LV hypertrophy is present) • Valvular heart disease • Heart failure • Coronary artery disease • AF may also be associated with: • Cardiomyopathy • Congenital heart disease (especially atrial septal defect in adults) Other Causes • Thyrotoxicosis • Rheumatic heart disease • Digoxin Toxicity • COPD • 5% unexplained Impacts on health and wellbeing • Heart failure: 20-30% of all AF patients have LV dysfunction • hospitalised every year% of AF patients are • Cognitive decline and vascular dementia; more common in those with AF than those without • Decreased quality of Life and depression; more common in those with AF Risk of AF Increases Along the Cardiovascular Spectrum Remodelling Ventricular dilation MI Heart failure End-stage Atherosclerosi s microvascular and LVH and heart disease Risk factors AF 1,2 (diabetes, Death hypertension ) 1. Benjamin EJ, et al. JAMA 1994; 271: 840–4; 2. Krahn AD, et al. Am J Med 1995; 98: 476–84 AF as a Co-Morbidity Makes bad things worse • Increased mortality after MI • Increased mortality after stroke • Increased risk of stroke recurrence • Worsening of heart failure • Increased risk of sudden cardiac death in advanced heart failure • Increased hospital admissions and length of stay in all casesAnatomy of the HeartThe Conduction System Symptoms of AF  Patients withAF present with a wide range of symptoms, or can be asymptomatic HEADEDNESS PALPITATIONS SYNCOPE DYSPNOEA FATIGUE CHEST PAINWe have to look for it…We have to look for it… Or it finds us • If new onset AF with life-threatening haemodynamic instability then refer for emergency electrical cardioversion without delaying to achieve anticoagulation. • For new onset AF without life-threatening haemodynamic instability lasting <48 hours, assess CHA2DS2VASc score and offer anticoagulation where indicated plus either rate or rhythm control. If onset >48 hours, offer anticoagulation where indicated and rate control. • NICE 2021 Impacts on health and wellbeing • Heart failure: 20-30% of all AF patients have LV dysfunction • hospitalised every year% of AF patients are • Cognitive decline and vascular dementia; more common in those with AF than those without • Decreased quality of Life and depression; more common in those with AF The Definition of AF “Atrial fibrillation is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation” NICE. Atrial fibrillation. The management of atrial fibrillation, June 2006.The ECG in AFNormal ECG ECG Diagnosis of AF Irregular RR interval QRS complexes are irregularly irregular Can be narrow or broad QRS Absent or indistinct P waves Baseline can show • Nothing • Irregular “noise” • Coarse activity a bit like flutter No regular patternECG Diagnosis of Atrial Flutter Classification of AF Terminology Clinical features Pattern Initial event Symptomatic May or may (first detected Asymptomatic not reoccur episode) Onset unknown Paroxysmal Spontaneous Recurrent termination <7 days and most often <48 hours Persistent Not self-terminating Recurrent Lasting >7 days or prior cardioversion Permanent Not terminated Established (‘accepted’) Terminated but relapsed No cardioversion attemptThe AF we find….. NEW NICE: Diagnosis: • Perform manual pulse palpation if AF suspected. Perform 12-lead ECG in people with an irregular pulse, with or without symptoms, to diagnose AF. • If paroxysmal AF is suspected use 24-hour ambulatory ECG monitor if episodes <24 hours or 24-hour ambulatory ECG, event recorder or other ECG technology for an appropriate period if episodes >24 hours apart.What to do AF confirmed Exclude/treat Symptom free underlying and cardiac Stroke cause stability prevention 179 AF confirmed Exclude/treat Symptom free underlying and cardiac Stroke cause stability prevention 180Exclude or treat underlying cause • Bloods- U&Es, TFTs , CVD risk profile ( cholesterol, HbA1C) 6 • 12 lead ECG- or ambulatory if paroxysmal • Echocardiogram – for assessment of cardiac function 181 AF confirmed Exclude/treat Symptom free underlying and cardiac Stroke cause stability prevention 182Symptom free and cardiac stability Improve heart rate: ( rate control) Aim for a resting heart rate of <110bpm AND without symptoms or continue till HR<85bpm in those with ongoing symptoms BOR C (+ D ) of drug options Rate limiting Beta-blocker O calcium channel Digoxin R blocker 183Rhythm options Ifsomeone remains symptomatic or intolerant of the rate control medication then refer for consideration of rhythm management, Rhythm Options: 1. Medication: (such as amiodarone, flecainide) 2. DC cardioversion 3. Ablation Note: AF never resolves, so anticoagulation should continue long term irrespective of current rhythm. 8 184 AF confirmed Exclude/treat Symptom free underlying and cardiac Stroke cause stability prevention 185 CHA DS -V2Sc 2 Risk factor score Congestive heart failure/LV dysf1nction C H Hypertension 1 A 2 Age ≥75y 2 D Diabetes mellitus 1 S 2 Stroke/TIA/TE 2 Vascular disease (prior myocardial V infarction, peripheral artery di1ease, ormaximum aortic plaque) score is 9 Age 65-74y since age A 1 Score Sc Sex category (ie female gender) 1 of 2 or Maximum Score 9 more = high Lip GY, et al., Chest 137, 263-272, 2010 HAS-BLED Letter Clinical Characteristic Points Awarded H Hypertension 1 Abnormal renal and or A liver function (1 point 1 or 2 each) S Stroke 1 B Bleeding 1 L Labile INR 1 E Elderly (age >65) 1 Drugs and or alcohol (1 D 1 or 2 point each) Maximum 9 points 7/14/2023 HAS-BLED Letter Clinical Characteristic Points Awarded H Hypertension 1 Abnormal renal and or A liver function (1 point 1 or 2 each) S Stroke 1 B BORBITng 1 L Labile INR 1 E Elderly (age >65) 1 D Drugs and or alcohol (1 1 or 2 point each) Maximum 9 points 7/14/2023 Aspirin • Great for heart attacks! …..not how clots form in AF! Risk of stroke and intra-cranial haemorrhage on warfarin according to INR 10 9 p 8 0 7 1 6 e 5 p a 4 r 3 2 1 0 <1.5 1.5-1.9 2-2.5 2.6-3 3.1-3.5 3.6-3.9 4-4.5 >4.5 INR stroke Intracranial haemorrhageDOACS Caution…. • *Apixaban dose should be reduced to 2.5 mgs if any 2 of the following apply: • Over 80years old • <60kgs in weight • Serum Creatinine> 133 • Rivaroxaban MUST be taken WITH food- without food the bio-availability is reduced to 65% ( WITH food it is almost 100%) • Dabigatran cannot be used out of the packet so is not suitable for “dosette boxes” Long term monitoring • Adherence • Adverse events • Additional/new medications ( including OTC) • Suggested bloods: • ALL- annual LFTs and FBC • CrCl >60 Annual U&Es • CrCl 30-60 6 monthly U&Es • CrCl 15-30 3 monthly U&Es Remember • Age • Body weight • Creatinine Clearance • Drug interactions • Remember: with every prescription we must think concordance