The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay


Bradford VTS Clinical Resources







Information provided on this medical website is intended for educational purposes only and may contain errors or inaccuracies. We do not assume responsibility for any actions taken based on the information presented here. Users are strongly advised to consult reliable medical sources and healthcare professionals for accurate and personalised guidance – especially with protocols, guidelines and doses. 

COME AND WORK WITH ME… If you’d like to contribute or enhance this resource, simply send an email to We welcome collaboration to improve GP training on the UK’s leading website, Bradford VTS. If you’re interested in a more active role with (and get your name published), please feel free to reach out. We love hearing from people who want to give.


Hypertension at a Glance

  • < 130/80 if the patient has other Chronic Disease (CVD/DM/CKD/TIA/CVA/PVD)
  • < 140/90 if only hypertension
  • < 150/90 if over 80 years for all conditions
  • A clinically significant white-coat effect is an office or clinic blood pressure exceeding the daytime ABPM by
      • 20 mm Hg systolic or
      • 10 mm Hg diastolic
  • either in the absence or presence of antihypertensive drug treatment

For African Caribbeans < age 55

  • follow the standard anti-hypertensive Rx pathway
      • 1st-line: use Amlodipine (or thiazide if not tolerated)
      • 2nd-line: Add ACEI (Ramipril) or ARB (Losartan or Candesartan)
      • 3rd-line:  Add thiazide

for African Caribbeans >age 55

  • 1st-line: use Amlodipine (or thiazide if not tolerated)
  • 2nd-line: Add ARB like Losartan or Candesartan (not ACEI)
For African Caribbeans + any age + HTN + diabetes 
  • 1st-line: ACEI like Ramipril
  • 2nd-line: Stop ACEI, replace with ARB like Losartan or Candesartan

Why ARB instead of ACEI?

I tried to look this up on the internet and it was difficult to find the answer.  SO the following is based on my supposition, going back to our biochemistry medical student days…  If you know the correct answer, please let me know

Blood pressure is reduced because ACE inhibitors block an enzyme early in the system, resulting in lower production of angiotensin, which can narrow blood vessels. ARBs, meanwhile, help blood vessels avoid constriction by blocking receptors to which angiotensin attaches. African caribbeans produce less renin. So there is less ACE circulating anyway. So no point giving ACEI. But instead give ARB which blocks the receptor onto which the remaining low levels of ACE attach. I think that’s the theory.  But from what I can see on the research front – this is not seen in real practice. The only good thing about ARB over ACEI is less side effects. So perhaps their trying to increase concordance. But then why not do this for everyone?

The Term African Carribean

The Afro-caribbean term is now replaced by African Caribbean (one r, two b’s).  African Caribbeans.are persons of African descent born or living in a Caribbean nation.   The Caribbean nations are those islands in North America which includes Jamaica and the Bahamas.  


  • Add additional therapy if BP>TARGET (consider clinical judgement and patient tolerance)
  • If have confirmed diagnosis of hypertension, amend medication based on clinic reading, do not delay by repeating BP readings or awaiting home BPs unless strong hx of white coat effect.



  • < 130/80 if the patient has other Chronic Disease (CVD/DM/CKD/TIA/CVA/PVD)
  • < 140/90 if only hypertension
  • < 150/90 if over 80 years for all conditions



What you do next depends if they have symptoms & examination signs indicating target organ damage (see examination box on right)

(symptoms like chest pain, headaches, fits, funny turns)
(signs like retinal haemorrhage, papilloedema, confusion, HF signs, proteinurea)


  • before you do anything, do an ECG & ACR (for end organ damage signs like LVH, ST changes, dysrhythmia)
      • if any signs of end organ damage – (2) start standard treatment antihypertensive Rx (like Amlodipine)  AND (2) get them to do AMBP/HMBP and (3) review within 7 days
      • if no signs of end organ damage – no need to start treatment – instead: (1) arrange AMBP/HMBP and (2) review within 7 days – then decided on Rx.   AMBP/HMBP will help exclude white coat hypertension.  


  • admit to hospital same day
  • Also refer same day if you suspect PHAEOCHROMOCYTOMA: labile/postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis (excessive sweating for no apparent reason)


  • admit to hospital – strict bed rest
  • do not add any antihypertensives because you do not want reduce blood pressure too rapidly because of possible cerebral infarction – instead let the hospital do it.
  • hospital will aim to reduce the blood pressure to 110 mm Hg diastolic over 24 hours


    • remember: eyes-brains-lungs)
        • visual disturbance (eyes)
        • headache (brain)
        • hypertensive encephalopathy – blunting of conscious level, confusion, coma, epileptic seizures (brain)
        • breathlessness (lungs)


  • acutely high BP with diastolic greater than  220/120 mmHg
  • EYES: fundoscopy: hypertensive retinopathy – with haemorrhages and exudates visible on the retina; papilloedema – from cerebral oedema
  • KIDNEYS: test urine – renal failure – dipstick for proteinuria
  • HEART: assess for cardiac failure – SOB, bibasl creps, worsening ankle oedema
  • Rarely, haemoglobinuria, jaundice and anaemia (microangiopathic haemolytic anaemia)

Options: A – ACEi or ARB; B – beta blocker; C – calcium channel blocker; D – thiazide like diuretic





No diabetes

–          ACR< 30 – use Standard guidance as above

–          ACR>30 – offer A

With diabetes

–          ACR>3 – offer A

All patients with ACR >70, offer A

Diuretics will be key second line drugs

–          eGFR>30, use D (higher doses or bd

–          eGFR<30, use loop diuretics (higher doses or bd)

Caution with spironolactone in CKD.  Start low dose, check u+es a week later or a week alter after dose adjustment and consider monitoring every 3 months.

Chronic heart failure

·         Patients should already be on A and B

·         If BP remain poorly controlled, add D (unless already on loop diuretic)

·         If control remains poor on A+B+D, get specialist advice on adding spironolactone or eplerenone

For B, first line bisoprolol

Spironolactone monitoring as above

Type 2 Diabetes

Non-black patients

–          Start with A and add D and C as 2nd and 3rd line

Black patients

–          A+D or A+C    1st line

–          A+C+D             2nd line

If triple therapy fails, consider a-blocker, B or spironolactone.

In women of child bearing age, C is first line (nifedipine in pregnancy)


Aim is to get BP down. 

A are not superior to other hypertensives at reducing renal and cardiovascular endpoints.

Most patients need combination therapy.

Type 1 Diabetes

·         A is first line

·         D or C as second line choices


Atrial Fibrillation

·         If HR needs to be controlled consider adding either a b-blocker or a rate limiting CCB (e.g.  diltiazem) to any existing therapy

·         If already taking amlodipine, consider changing to a rate limiting CCB e.g diltiazem.



  • Monthly review WITH treatment change until BP below target, thereafter annual BP review, bloods and medication review as per CDM review table.
  • Lipid Rx: As per lipid modification protocol
  • Consider ABPM/HBPM as an adjunct to clinic BP measurements to monitor the response to anti-hypertensive treatment with life-style modification or drugs, if increasing medication will be poorly tolerated, avoiding polypharmacy, white coat effect, patient resistance.
  • Hypertension in women of childbearing age/Hypertension in Pregnancy: Refer to appropriate NICE guidance 107
  • Advice re: AKI Sick Day Rules

Advise patients the following to prevent ACUTE KIDNEY INJURY/DAMAGE when they are unwell

If you do go down with a cold, flu or any other illnesses like vomiting or diarrhoea (unless only minor)…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or urgent medical services (111 or A&E if in the UK)
  • Stop taking the medications listed below  (Mnemonic: DAAMN)
      • DIURECTICS – furosemide, spironolactone, indapamide, bendroflumethazide
      • ACE-inhibitors – lisinopril, perindopril, ramipril
      • ARBs – losartan, candesartan, valsartan
      • NSAIDs – ibuprofen, diclofenac, naproxen
  • Restart the medication when you are well
      • Usually 24-48 hours of eating and drinking normally

Heart Failure at a Glance

These guidelines apply to those with chronic heart failure due to reduced LV ejection fraction or LV systolic dysfunction. In patients with preserved ejection fraction >50%, or diastolic heart failure, the evidence base for treatment remains unclear.


  • Breathlessness on exertion and at rest + reduced exercise tolerance
  • Orthopnoea, PND (Paroxysmal Nocturnal Dyspnoea)
  • Nocturia
  • Swollen ankles, Swollen abdo (patients say bloating and weight gain)
  • Increasing fatigue   (+/- lightheadedness/syncope)


  • Tachypnoea (SOB)
  • Tachycardia >100 bpm
  • High BP
  • Auscultation Lungs: Fine basal crepitations +/- pleural effusion
  • Auscultation Heart: laterally displaced apex beat and heart murmur, Gallop Rhythm at the apex (3rd/4th heart sounds) – 
  • fluid retention – ankle, abdominal. sacral oedema
  • Age >65
  • IHD, hypertension, AF, valvular heart disease, cardiomyopathy, myocarditis
  • renal failure
  • anaemia
  • thyrotoxicosis

Don’t forget…

  • Family HX of heart failure + sudden cardiac death under the age of 40 years
  • Drugs that can cause HF:
      • alcohol,
      • cocaine;
  • Drugs that can worsen HF symptoms:
      • NSAIDS,
      • Calcium channel blockers
  • Blood tests: FBC, U+Es, TSH, LFT, Hba1c, lipid profile, BNP
  • Urine dip for blood and protein
  • ECG
  • CXR
  • Spirometry/Peak flow (to exclude lung causes of SOB)
  • ECHO – see dx section.
  • If LVSD already confirmed via previous ECHO then bloods performed to assess for contraindications to medications

Previous MI

  • URGENT referral HF clinic and ECHO within 2/52

Symptomatic HF with no previous HX of MI:

  • Measure NT- pro BNP (NICE & ASSIST)
      • >2000 pg/ml (236 pmol/l) — URGENT REFERRAL for specialist assessment + ECHO in 2 weeks
      • 400 – 2000 pg/ml ——- refer for specialist assessment  + ECHO in 6 weeks
      • <400 pg/ml —— diagnosis of HF less likely —- Consider discussion with specialist if still symptomati

Pregnant women (or women 6 months post-natal) with suspected HP

  • emergency admission/ refer specialist

HF with valve disease

  • refer for specialist assessment

BEWARE: Other causes of a raised BNP

  1. Age >70
  2. Other cardiac things – LVH, Ischaemia, Tachycardia, RV overload,
  3. Hypoxaemic conditions – e.g. COPD, PE
  4. Renal: when GFR <60,
  5. Diabetes
  6. Liver Cirrhosis
  7. Sepsis

BEWARE: BNP levels are reduced by

  • Heart failure treatment – such as ACE, diuretics and beta-blockers.
  • Grade I:          No limitations
  • Grade II:        Some limitation of normal activity   (15%  mortality at 12 months)
  • Grade III:      Severe limitation of normal activity  (30% mortality at 12 months)
  • Grade VI:       SOB at rest (60% mortality at 12 months)
  • Classification is important as it defines prognosis and optimal treatment – it must be recoded in all cases using the specified Read code.

Some Key Rules

  • Review medications that can worsen symptoms –
      • NSAIDS,
      • Calcium channel blockers
  • ONLY ADD 1 DRUG AT A TIME – according to clinical judgement
  • HF with preserved EF – manage co-morbidities (HTN/ IHD/DM) in line with NICE guidelines
  • HF due to left ventricular systolic dysfunction – 1st line management ACEi (or ARBII) + Beta blockers
  • Primarily used for symptom control.
  • Once pulmonary congestion and oedema controlled and, estabished HF treatment on board, diuretics can be stopped.
  • Daily self weighting can be a useful guide as to whether fluid is collecting and diuretics are needed. Advise patients to contact their GP if more than 5-2 kg weight gain in 2 days.
  • Titrate dose ↑ or ↓ according to symptoms
  • Measure renal function + BP before initiating medication and 1-2 weeks after starting treatment (NICE)
  • Earlier monitoring in 5-7 days in those with existing CKD stage 3 or higher and in those >60 years (NICE)

Recommended Loop Diuretic (NICE) – European society of cardiology,2012 & BNF 72, 2016





20 – 40 mgs

20-120 mgs


0.5 – 1mg

1 – 5 mgs


5 – 10 mgs

10 – 20 mgs

  1. For patients with confirmed HF + preserved EF: MAXIMUM DOSE FUROSEMIDE 80 mgs (NICE)
  2. Educate patients to adjust dose according to weight — DISCUSS with GP if weight gain 1.5 -2 kgs gain/2 days
  3. Avoid excessive fluid intake —- 1.5 litre fluid intake per day (ASK them to maintain a fluid diary)

IF develops D&V:

  • Maintain fluid intake
  • STOP diuretic for 1-2 days until recovered
  • If persistent >2 days —- then contact GP —– will need bloods (renal) + BP +/- referral to secondary care
  • Re initiating diuretic —- start at lower dose

ONCE Rx stabilised

  • Measure UE’s at least once every 6 months (NICE).

Other means of symptom control for breathlesness

  • Oramorph/lorazepam
  • Hand held fan.
  • The palliative care team are a useful resource for advice and support regarding symptom control.
  • Contraindicated
      • if Cr > 150, K+ > 5.5 and/or renal artery stenosis
      • angioedema,
      • significant aortic stenosis or valvular disease
      • In all these situations, refer.
      • CAUTION in women of childbearing age and contraindicated if trying to conceive or pregnant.
  • If U&Es pre treatment reveal a Cr < 150 micromol/l, K+ < 5 and a Na+ >130 mmol/l then
      • 2.5 mg Ramipril daily (1.25mg if on concomitant diuretics) for one week with check U&Es
      • and then an increase to 5.0 mg Ramipril for a further three weeks.
      • Re-check U&Es 1-2 weeks after each dose increment and attempt to up titrate all patients to the 10mg dose.
      • Thereafter repeat U&Es on an annual basis.
  • If eGFR change > 25% or Cr rise > 30% then:
      1. Ix for other causes e.g. concurrent NSAID or fluid depletion,
      2. if no concurrent cause found either stop ACEi or reduce to previously tolerated dose.
  • Patients intolerant of ACEi
      • can try an ARB e.g. Candesartan.
      • ARB may also be used in addition to ACE in patients with severe HF (NYHA 3 and 4) who continue to be symptomatic.
      • Recent evidence suggests that Candesartan may have benefits over other ARB licensed for HF (currently Losartan).
  • If intolerant to ACEI & ARB
      • refer to secondary care or consideration of hydralazine & nitrate.
  • If K+ > 6
  • WARN patients improvement in symptoms over weeks to months.
  • In addition to normal treatment NYHA grade I, II and III should have a trial of a betablocker e.g. bisoprolol
  • This should include patients with COPD, PVD, diabetes and ED.
  • This should be a slow up-titration with regular review – consider referral to the Heart Failure Nurse Practitioner.








Bisoprolol (mg)     







  • Consider back dose titration if the patient develops symptomatic hypotension, asymptomatic systolic BP < 90mmHg, bradycardia < 50bpm or respiratory symptoms.
  • All new diagnosed cases
  • Symptomatic despite above treatment
  • Managing severe HF (NYHA class IV), HF not responding to treatment.
  • HF due to valve disease
  • HF which can no longer be managed at home.
  • Pregnant or preconception

2nd Line

    • Aldosterone Antagonists e.g. spironolactone (K+ needs to be less than 6)
    • ARB in conjunction with ACEi
    • Hydralazine nitrate (esp if African/Caribbean’s and those intolerant to ACEi/ARB)

3rd Line

  • Cardiac Resynchronisation
  • ICD – implantable cardiac defibrillator
  • CABG, LV assist device, cardiac transplant
  • Digoxin
  • Ivabradine
  • Entresto (Sacubitril/Valsartan) 


  • Avoid in renal impairment and/or diabetic nephropathy.
  • Monitor U&E’s 6 MONTHLY.
  • HALVE dose if K+ rises between 5-5.9.
  • STOP if K+ >6 or Cr > 220



  • SA node inhibitor.
  • Pulse has to be 75 or more, sinus rhythm.
  • Only initiated after 4 weeks stabilisation period on standard therapy.


  • Routine digoxin levels not needed unless toxicity suspected, in which case, levels should be taken 8-12 hours post dose. BEWARE toxicity can still occur with normal digoxin levels.
  • Symptoms of toxicity include: arrythmia, anorexia, nausea, vomiting, diarrhoea, confusion, yellow vision, blurred vision, photophobia.


  • Paces both ventricles and Rt atrium to improve contraction.


  • Patients with acute MI & LVD benefit from Eplerenone (an aldosterone antagonist) post MI, so you may see some patients discharged on this.
  • Can also be given if patients develop gynaecomastia on spironolactone.

ENTRESTO (Sacubitril/Valsartan)

  • New class of drug – ARNI (angiotensin receptor-neprilysin inhibitor)
  • Nepriylsin inhibition affects the ability of natriuretic peptides to cause vasodilatation and also inhibits the renin-angiontensin system and has an anti-hypertrophy effect.
  • NOT used with ACEI/ARB.


  • Pulse, BP & BMI
  • ECG
  • Update NYHA classification
  • Medication review, assign diagnosis to repeat template
  • Smoking status/cessation advice
  • Alcohol intake and advice
  • Lipid modification
  • Annual Flu vaccination and Pneumovac
  • Bloods as per CDM review table within the last 12 months  (CDM = chronic disease management)
  • Add recall
  • Consider palliative and end of life care when appropriate to do so, usually in patients with advanced heart failure with on-going symptoms despite optimal management.
  • Consider low dose opioids, titrated against effect, in patients with dyspnoea





Try to avoid   (Mnemonic NET CCC)

  • NSAIDs like ibuprofen, naproxen
  • Effervescent preparations e.g. eff Solpadol, as these have a high sodium content.
  • Tricyclics antidepressants like amitriptyline
  • Ca Channel Blockers like Diltiazem
  • Corticosteroids like prednisolone
  • COX II inhibitors like celecoxib

Advise patients the following:

Tummy bugs which result in vomiting and/or diarrhoea can easily lead to dehydration.   Even flu-like symptoms and coughs and colds with a fever can lead to dehydration through increased sweating.   

  • When you are dehydrated, certain drugs for heart failure can be harmful.
  • These drugs should be temporarily stopped to prevent subsequent side effects.
  • You can restart these medications once you are feeling better
  • Medications to stop: ACEi/ARBII/Diuretics/other antihypertensives/NSAIDS
  • If symptoms persist >2 days, call doctor to reassess.


  • Avoid too much caffeine as this could make you dehydrated.
  • Keep weighing yourself on a daily basis to help your heart failure specialist adjust your medication while you are dehydrated.
  • It may be adequate to slightly and temporarily increase your fluid intake during the dehydration period, but return to your usual daily limit as soon as your dehydration state is resolved and follow the directions of your heart failure specialist.
  • Over-the-counter anti-inflammatory drugs such as ibuprofen, diclofenac (eg. Voltaren emulgel®) or naproxen must be avoided to treat fever or pain. Acetaminophen remains the preferred option in such situation.
  • WARNING Some over-the-counter products for cold and flu contain anti-inflammatory ingredients. Always refer to your pharmacist before using such products.

What the doctor should do:

  • Assess hydration status – tongue, skin turgor etc – and do a BP
  • Stop medications : ACEi/ARBII/Diuretics/other antihypertensives/NSAIDS) for 1-2 days; restart when eating and drinking normally (NICE)
  • If symptoms persists >2 days
      1. Continue to withhold meds
      2. Do some obs – T, Pulse, BP, O2 sats
      3. +/- Refer to secondary care

Signs of dehydration

MILD dehydration

  • Dry mouth
  • Light-headedness
  • Headache

SEVERE dehydration
Also includes the symptoms mentioned above, plus…

  •  Intense thirst
  • Lower blood pressure than usual
  • Reduced urine output and darker urine

Weigh yourself at home

  • Same time per day
  • If weight ↑ >2 kgs in 3 days – advise ↑diuretic dose and ↓fluid intake

Salt Consumption

  • Do not to exceed >6 gms per day  
  • Direct patient to British Heart Foundation + British Dietetic Society

Fluid Balance

  • In severe symptoms RESTRICT to 1.5 – 2 litres per day

Smoking Cessation

  • Alcohol
  • Stick to recommended levels


  • Regular low intensity physical activity if stable HF

Taken from NICE & ASSIST (2023)


  • Main symptoms – breathlessness, persistent coughing, cardiac ischaemia pain, intense fatigue, severe limitation of physical activity & oedema.  
  • Other symptoms: loss of appetite & nausea, constipation, depression & anxiety, insomnia


  • Liaise with cardiology + Palliative care
  • Predicting treatment trajectory.  Can be difficult to predict, but base on..
      • Frequent hospital admissions: 3 or more admissions in last 12 months
      • Poor response to Rx, breathlessness (NYHA IV)
      • Presence of cardiac cachexia, ↓ serum albumin
      • Progressive ↓ eGFR + hypotension
      • Poor quality of life + dependence on others for ADL
      • On home O2



  • Low dose oromorph/Lorazepam/Diazepam
  • Can use GTN spray but contraindicated in severe aortic stenosis

Cardiac ischaemia pain

  • morphine + nitrates

Stroke & TIA at a Glance

Carers may use FAST tool to assess symptoms:

  • Facial weakness – can they smile, is face drooping?
  • Arm weakness – can the person raise both arms?
  • Speech problems – can they speak clearly and understand what you are saying?
  • Time to call 999

If you suspect a Stroke 

  1. Admit to hospital – Call 999.  
  2. Do not give Aspirin pending scan and possible thrombolysis

Differentials  (MESH-D)

  • Migraine,
  • Epilepsy,
  • Sepsis 
  • Hypogylcaemia
  • Other causes of Delerium   (alcohol, drugs, dehydration, dementia, UTIs, LRTIs, medicines, and advanced cancer)

A reminder

Primary prevention

Primary prevention aims to prevent disease before it ever occurs. This is done by preventing exposures to hazards that cause disease, altering unhealthy or unsafe behaviours that can lead to disease , and increasing resistance to disease should exposure occur. Examples include: immunising people (increasing resistance), statin in patients with high QRISK but no PMH of IHD.

Secondary prevention

Secondary prevention aims to reduce the impact of a disease that has already occurred. This is done by detecting and treating disease as soon as possible to halt or slow its progress, encouraging personal strategies to prevent or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: mammography to detect breast Ca early, clopidogrel for patients already had a stroke, low dose aspirin patients already had an MI

Tertiary prevention

Tertiary prevention aims to soften the impact of an ongoing illness that has lasting effects. This is done by helping people manage long-term, often-complex health problems  (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.)

Primary Prevention of Stroke

  • Maintaining a normal BP.
  • If QRISK> 10% consider atorvastatin 20mg (NICE) or 40mg (BHH).
  • If known IHD then lipid management decreases the risk of stoke, Atorvastatin 80mg.
  • All patients with valvular heart disease and AF should be considered for warfarin/NOAC. Only use the CHA2DS2Vasc score to determine anticoagulation use in patients with non valvular AF.
  • Healthy lifestyle advice – diet, alcohol, exercise and smoking cessation advice and treatment.

Secondary Prevention of Stroke

i.e. preventing the high risk ones from getting it

  • AF should be assessed and treated with warfarin/NOAC
  • BP – should be maintained at <130/<80 (BHH) (unless they have bilateral coronary artery stenosis <150/90).   BP lowering therapy if needs be.
  • All patients with a history of Ischaemic stroke should be on Clopidogrel in preference to low dose aspirin, as this reduces CVS mortality and recurrent stroke.
  • Patient’s with post ischaemic CVA should receive Aspirin & Dipyridamole if clopidrogrel not tolerated or contraindicated
  • Statins – all patients with a history of TIA/ischaemic stroke irrespective of age, sex or cholesterol level should be given Atorvastatin 80mg.
  • Smoking cessation and healthy lifestyle advice.
  • All patients with non disabling stroke or TIA should be considered for urgent specialist assessment – patients with high grade ipsilateral stenosis benefit from carotid endarterectomy.

If you suspect a Stroke 

Admit to hospital – Call 999.  

Do not give Aspirin pending scan and possible thrombolysis

A TIA is a brief blockage of blood flow to part of the brain, spinal cord or the thin layer of tissue at the back of the eye known as the retina. This blockage may cause temporary stroke-like symptoms. But a TIA doesn’t damage brain cells or cause permanent disability. This is how it differs from a regular stroke.

Assessing the risk of stroke post TIA using the ABCD2 score

A  (age)



1 point

0 point

B  (BP)


1 point

C  (Clinical features)

Unilateral weakness


Other symptoms

2 points

1 point

0 point

D   (Duration of symptoms)

≥ 60 minutes

10-59 minutes

< 10 minutes

2 points

1 point

0 point

D2 (Diabetes)



1 point

0 point

NICE recommends ALL suspected TIA to be referred without risk stratification ABCD2 score. However Bradford still uses the ABCD2

In Bradford, what you do depends on the ABCD2 score and frequencies of TIA

  • Suspected TIA AND ABCD2 score 4 OR ≥2 TIAs in a week 
      • Refer TIA clinic using updated form  (on ASSIST ) and fax form through asap as they need evaluation within 24 hours.  There may be a telephone number to use to speak to consultant on call.
  • Suspected TIA AND ABCD2 score < 4
      • Refer to TIA clinic using the updated form – should be seen within 1 week
  • Suspected TIA presenting after 1 week
      • Refer to TIA clinic  – should be seen within 1 week of referral

Other Important Management Things

  • If symptoms persist throughout your clinical examination, send patient to A+E (could be  a stroke!)
  • All patients with suspected TIA should be given 300mg Aspirin immediately and then continued as 75mg daily until they are seen in the TIA clinic. Can also offer Clopidogrel 75mg instead of Aspirin – preferred choice in Bradford.
  • TIA patients should not drive for one month – or until seen in the TIA clinic and told otherwise – document this advice
  • Any witnesses to the event should accompany patient to clinic
  • If experiences a further event before being seen in TIA clinic – go to A+E

Exclusion criteria for TIA clinic

  • Age <45 – refer Neurology
  • Loss of consciousness
  • Falls
  • Dizziness
  • Confusion
  • Incontinence
  • Amnesia
  • Isolated vertigo/diplopia/dysarthria
  • Sensory symptoms confined to part of one limb or face

CHA2DS2-VASc for people with AF

  Condition Points
 C   Congestive heart failure (or Left ventricular systolic dysfunction) 1
 H  Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1
 A2  Age ≥75 years 2
 D  Diabetes Mellitus 1
 S2  Prior Stroke or TIA or thromboembolism 2
 V  Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1
 A  Age 65–74 years 1
 Sc  Sex category (i.e. female sex) 1

In clinical use, the CHADS2 score has been replaced by the CHA2DS2-VASc score, which gives a better stratification of low-risk patients. 

Thus, the CHA2DS2-VASc score includes additional common stroke risk factors of 3 things: age 65–74, female gender and vascular disease.  In the CHA2DS2-VASc score, ‘age 75 and above’ also has extra weight, with 2 points.  

The maximum CHA2DS2-VASc score is 9 (not 10, as might be expected from simply adding up the columns because the maximum score for age is 2 points = 0 if <65, 1 if 65-74, 2 if >=75).

CHA2DS2-VASc score

of Stroke
































Different stroke studies say different things about annual stroke risk rates based on CHA2DS2VASc score.  This table shows an average but the confidence intervals can be wide.   Stroke rates vary by study setting (hospital vs community), population (trial vs general), ethnicity, etc. 

Different stroke studies say different things about annual stroke risk rates based on CHA2DS2VASc score.  This table shows an average but the confidence intervals can be wide.   Stroke rates vary by study setting (hospital vs community), population (trial vs general), ethnicity, etc. 

The predictive abilities of risk scores for ischemic stroke in patients with kidney function impairment is questionable: a large study demonstrated poor discrimination and calibration in patients with reduced kidney function (de Jong et al, 2021).

Anticoagulation basically reduces the risk by about 50%.   So, someone with a 4% annual stroke risk prediction, on anticoagulation will have a 2% annual stroke risk prediction.  Please note, putting someone on anticoagulation therapy does NOT eliminate the annual stroke risk – it reduces it.  But many doctors explain it to patients in a way that makes patients think by going on this treatment, their risk has gone; but this is not the truth.   Also, don’t forget there is a bleed risk with anticoagulants of roughly the order of 2-3% per year. Some of these will prove fatal – see HASBLED score.  All these things should be explained to the patient so they can make the appropriate choice for them as individuals.

  Condition Points
 H   Hypertension: (uncontrolled, >160 mmHg systolic)

 Abnormal renal function: dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L

Abnormal liver function: cirrhosis or bilirubin >2x normal or AST/ALT/AP >3x normal


 S  Stroke: prior history of stroke
 B  Bleeding: prior major bleeding or predisposition to bleeding
 L  Labile INR: unstable or high INR or Time in Therapeutic Range < 60%
 E  Elderly: age > 65 years

Drug Medication – such as antiplatelet agents, SSRIs, NSAIDs (i.e. predispose to bleeding)
Alcohol  (≥ 8 drinks/week) 



A calculated HAS-BLED score is between 0 and 9 and based on seven parameters with a

The HAS-BLED score stimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.

A score of ≥3 indicates “high risk”, but does not necessarily mean that an anticoagulant cannot be given, as some risk factors may be modified.  Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.


0 = 1 bleed per 100 patient years

1 = 1 bleed per 100 patient years

2 = bleeds per 100 patient years

3 = 4 bleeds per 100 patient years

4 = 9 bleeds per 100 patient years

5 = 10 bleeds per 100 patient years

6, 7, 8, 9 =  to rare to determine accurate risk.  Most likely over 10 percent will bleed.

  • Anti-platelets not recommended unless very high risk CVD risk
  • Statins are not routinely recommended
  • Specialist advice recommended
  • BP lowering non acutely, as for ischaemic stroke
  • Read code STROKE/TIA for QoF
  • Promote to problem and summary lists
  • Use appropriate S1 template/ARDENS
  • Add recalls for annual CDM review
  • Assign diagnosis to repeat template drugs

Do the following:

  • Bloods: U+Es, HbA1C plus (ALT at 3 months only if new or dose change of statin)
  • BP: follow hypertension protocol
  • BMI
  • Medication: ask about medication concordance & side effects, move review dates on, record medication review done
  • Depression screen
  • Lifestyle things
      • smoking status & cessation advice
      • alcohol advice
      • Carer details – any additional help required – ask carer how things are.

Don’t forget…

  • Do all of this by completing the S1 template (ARDENS)
  • See CDM review table
  • Nurses to follow Nurse led clinic protocol
      • Add Medication Reviewed & assign diagnosis to appropriate repeat meds
      • Move recall on 

Lipids & Statins at a Glance

These guidelines apply to those with chronic heart failure due to reduced LV ejection fraction or LV systolic dysfunction. In patients with preserved ejection fraction >50%, or diastolic heart failure, the evidence base for treatment remains unclear.

  • If a patient’s LDL is really high, then do they have a FH with variable penetrance?
  • In that case, we are then really in a secondary prevention conversation.
  • Classification is important as it defines prognosis and optimal treatment – it must be recoded in all cases using the specified Read code.

Statins might do loads of other advantageous things;

  1. They are vascular anti-inflammatory and they may reduce your risk of an ICU admission if you had Covid-19 for instance (CVD without statin increased your risk, but it was not a return to the median, they were beneficial).
  2. The anticancer properties of statins have been found in various cancers.  In a large Danish cohort, compared with patients who had never used statins, statin users presented with significantly reduced cancer-related deaths for 13 different cancer types, including breast cancer.A recent advance has been to implicate statins in potentiating anti-tumor immune responses in cancer.

The majority of people in the UK will die of either cancer or CVD,  then surely reducing the risk of one of these is enough! (PS They reduce the risk of metastatic spread as well)

Muscle pains is slightly more complex. Atorvastatin and Simvastatin are more lipophilic than Rosuvastatin and Pravastatin (does anyone seriously use Pravastatin any more???) but this does not seem to be the simple solution to muscle pain…just use rosuvastatin.  In reality you should:

  • Always start with atorvastatin (40mg primary prevention and 80mg secondary prevention)
  • If muscular pain, check CPK and stop. We really should check the CPK as if this is raised you should not really reintroduce a statin. Also if elevated important to recheck 4-6 weeks later as you will find those who have elevated levels not due to statins
  • If CPK is acceptable wait 6-8 weeks and see if the pain settles (most it makes no difference as it was never the statin in the first place) if not we have 2 choices
        • give the same statin back but up titrate to the previous dose over a few weeks. Over 70% will be able to take the previous statin without pains. However this suggestion usually get quite a blunt response from our Yorkshire patients, often resorting to their Anglo-Saxon linguistic roots!
        • Give them a statin from the other family. Most of us in the UK only use atorvastatin and rosuvastatin – this makes life easier; if they have had atorvastatin give them rosuvastatin and vice versa

But what if the patient doesn’t want a statin because of the exaggerated bad media press?  Or what about those patients who say they want to give it a go themselves first or with more natural things like plant sterols?

If a person in primary prevention wishes to amend their diet, that is up to them. Statins have evidence in a primary prevention setting and all the rest is window dressing, and in the case of plant sterols – like you find in margarines and yoghurts – very expensive window dressing!   

The food industry has created a multi-million-pound market out of the desire to cut cholesterol.  Studies have shown that margarines such as Benecol and Flora pro.activ can reduce the level of harmful fats in the blood.  But they are also up to four times as expensive as conventional margarines.  They often claim a 14-15% reduction just after four weeks – but only if patients use enough spread to cover four slices of bread daily!!!!  

If people really want to address their lipids in a primary prevention setting, they will do better watching their alcohol and refined carbohydrate most of the time. 

Secondary prevention is harder.

  • 1 in 4 people die immediately from their infarct, and this is getting worse again.
  • Of those who survive the initial acute event nearly ALL will die of vascular events.

All their health risk is before them (well they aren’t dead yet) and if you want to reduce the risk, take the tablets and improve your lifestyle. Yes lifestyle change will reduce risk but this is in addition to the medication. If a patient chooses to not take meds, then that is a patient’s choice, but it is important that they understand that their risk of further events has increased. It is that simple.

If you are a patient who has already had a heart attack or other cardiovascular event, then you are at war with cardiovascular disease.  Whether you like it or not, you have entered the fire fight.   Being one of the lucky ones who has survived say a heart attack, is a bit like a bullet which has hit your arm.     Being on a statin is a bit like having a flak jacket.    Do you really want to take it off knowing other bullets are heading your way?

PS a flak jacket = a sleeveless jacket made of heavy fabric reinforced with metal or Kevlar, worn as protection against bullets and shrapnel.

Ramadan & Fasting Advice for Cardiovascular Disease

Fasting is an obligation for competent, healthy adult Muslims although there are exemptions. Many of those who could seek exemption might still want to fast. It is important to respect this but it is advisable to start planning 6-8 weeks before Ramadan to avoid adverse outcomes e.g. patient self-adjustment of medication.

Who is exempt from fasting?

  • Acute or chronic illness
  • Travellers
  • Pregnant/breastfeeding*
  • Menstruating/postpartum bleeding
  • Children
  • Mentally unwell/lacks capacity

*Consensus by Islamic scholars that it is permissible not to fast if there is threat of harm to mother/child

The fast of Ramadan lasts from dawn to sunset for a period of 29 or 30 days. It follows the lunar calendar so is brought forward by about 10 days each year.   Fasting people generally eat two meals a day: often a smaller meal before dawn (Suhoor) and a larger one after sunset (Iftar).  No fluids or food are taken during daylight hours. This includes water and most medication.

Permissible interventions/medications

  • Blood tests
  • Vaccinations
  • Asthma inhalers*
  • Ear drops*
  • Eye drops
  • Transdermal patches

*Difference of opinions exist. Encourage patients to contact their local imam, or BIMA for advice.


Should I advise my patient not to fast?

BIMA have an interactive traffic light tool that help to classify patients into low/moderate risk, high risk, and very high risk at 

Patients in the two higher tiers should be advised that they ‘must not fast’ and ‘should not fast’ respectively. Consider advising these patients to fast in the shorter winter months. If they insist to fast, monitor regularly and ask that they should be prepared to break the fast in case of adverse events. Below is a shortened summary of the advice:


  • Advanced heart failure EF <35%
  • Severe pulmonary hypertension


  • Poorly controlled hypertension
  • Recent ACS <6 weeks
  • HOCM
  • Severe valvular disease
  • Poorly controlled arrythmias
  • Implantable cardioverter defibrillator


  • Stable hypertension
  • Stable angina
  • Mild heart failure
  • PPM (Permanent Pace Maker)
  • SVT/AF
Scroll to Top


Bradford VTS was created by Dr. Ramesh Mehay, a Programme Director for Bradford GP Training Scheme back in 2001. Over the years, it has seen many permutations.  At the time, there were very few resources for GP trainees and their trainers so Bradford decided to create one FOR EVERYONE. 

So, we see Bradford VTS as  the INDEPENDENT vocational training scheme website providing a wealth of free medical resources for GP trainees, their trainers and TPDs everywhere and anywhere.  We also welcome other health professionals – as we know the site is used by both those qualified and in training – such as Associate Physicians, ANPs, Medical & Nursing Students. 

Our fundamental belief is to openly and freely share knowledge to help learn and develop with each other.  Feel free to use the information – as long as it is not for a commercial purpose.   

We have a wealth of downloadable resources and we also welcome copyright-free educational material from all our users to help build our rich resource (send to

Our sections on (medical) COMMUNICATION SKILLS and (medical) TEACHING & LEARNING are perhaps the best and most comprehensive on the world wide web (see white-on-black menu header section on the homepage).