Partilhar
array:23 [ "pii" => "S0870255122000737" "issn" => "08702551" "doi" => "10.1016/j.repc.2022.01.007" "estado" => "S300" "fechaPublicacion" => "2023-06-01" "aid" => "1919" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2023;42:557-78" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0870255123001683" "issn" => "08702551" "doi" => "10.1016/j.repc.2022.08.014" "estado" => "S300" "fechaPublicacion" => "2023-06-01" "aid" => "2163" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2023;42:579-80" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Percutaneous mitral valve repair in a multioperated congenital heart disease patient. The importance of alternative echocardiographic views" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "579" "paginaFinal" => "580" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Reparação percutânea da válvula mitral num doente com cardiopatia congénita multioperada. Importância de incidências ecocardiográficas alternativas" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1388 "Ancho" => 3258 "Tamanyo" => 430523 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel Tébar, Alfonso Jurado-Román, Lucía Fernández-Gassó, Guillermo Galeote, Santiago Jiménez-Valero, Raúl Moreno, Esteban López de Sá" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "Tébar" ] 1 => array:2 [ "nombre" => "Alfonso" "apellidos" => "Jurado-Román" ] 2 => array:2 [ "nombre" => "Lucía" "apellidos" => "Fernández-Gassó" ] 3 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Galeote" ] 4 => array:2 [ "nombre" => "Santiago" "apellidos" => "Jiménez-Valero" ] 5 => array:2 [ "nombre" => "Raúl" "apellidos" => "Moreno" ] 6 => array:2 [ "nombre" => "Esteban" "apellidos" => "López de Sá" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123001683?idApp=UINPBA00004E" "url" => "/08702551/0000004200000006/v1_202306021106/S0870255123001683/v1_202306021106/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0870255123001294" "issn" => "08702551" "doi" => "10.1016/j.repc.2023.03.004" "estado" => "S300" "fechaPublicacion" => "2023-06-01" "aid" => "2153" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2023;42:553-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Gut microbiota dysbiosis and cardiovascular disease – The chicken and the egg" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "553" "paginaFinal" => "555" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Disbiose da microbiota intestinal e doenças cardiovasculares – O ovo e a galinha" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Flávio Reis" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Flávio" "apellidos" => "Reis" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123001294?idApp=UINPBA00004E" "url" => "/08702551/0000004200000006/v1_202306021106/S0870255123001294/v1_202306021106/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "Practical approach to referral from primary health care to a cardiology hospital consultation in 2022" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "557" "paginaFinal" => "578" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Rui Baptista, Tiago Maricoto, Sílvia Monteiro, Jordana Dias, Sara Gonçalves, Helena Febra, Victor Gil" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Rui" "apellidos" => "Baptista" "email" => array:1 [ 0 => "rui.baptista@fmed.uc.pt" ] "referencia" => array:5 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 4 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Tiago" "apellidos" => "Maricoto" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 2 => array:3 [ "nombre" => "Sílvia" "apellidos" => "Monteiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 3 => array:3 [ "nombre" => "Jordana" "apellidos" => "Dias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 4 => array:3 [ "nombre" => "Sara" "apellidos" => "Gonçalves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 5 => array:3 [ "nombre" => "Helena" "apellidos" => "Febra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 6 => array:3 [ "nombre" => "Victor" "apellidos" => "Gil" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">l</span>" "identificador" => "aff0060" ] ] ] ] "afiliaciones" => array:12 [ 0 => array:3 [ "entidad" => "Cardiology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, University of Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Aradas Family Health Unit, ACES Baixo Vouga, Aveiro, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Intensive Cardiac Care Unit (UCIC), Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Guarda Customized Healthcare Unit, ACES Guarda, Guarda, Portugal" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Integrated Unit in Heart Failure (UNIICA), Cardiology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "São Julião Family Health Unit, ACES Lisboa Ocidental e Oeiras, Oeiras, Portugal" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Cardiology Department, Hospital da Luz, Lisbon, Portugal" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Faculty of Medicine, University of Lisbon, Lisbon, Portugal" "etiqueta" => "l" "identificador" => "aff0060" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Abordagem prática à referência de doentes dos cuidados de saúde primários para consulta hospitalar de cardiologia em 2022" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1249 "Ancho" => 2925 "Tamanyo" => 369696 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Suggested therapeutic regimen for the management of hypertension.<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a><span class="elsevierStyleSup">a</span>CKD is defined as eGFR<60 ml/min/1.72 m<span class="elsevierStyleSup">2</span> with or without proteinuria; <span class="elsevierStyleSup">b</span>preferential use of loop diuretics if eGFR<30 ml/min/1.72 m<span class="elsevierStyleSup">2</span>, due to thiazide diuretics or similar being much less effective when eGFR is reduced to these levels; <span class="elsevierStyleSup">c</span>caution: risk of hyperkalemia with spironolactone, especially when eGFR is less than 45 ml/min/1.72 m<span class="elsevierStyleSup">2</span> or when basal kalemia ≥4.5 mmol/L. ACEi: angiotensin converting enzyme inhibitor; AMI: acute myocardial infarction; ARB: angiotensin receptor blocker; BP: blood pressure; CCB: calcium channel blocker; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; HF: heart failure.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In Portugal, up to 38% of the population suffers from cardiovascular disease (CVD), which highlights the importance of primary health care (PHC) in its management. Among the most common diseases in the context of PHC are hypertension (27%), arrhythmias (3%), valvular diseases (2%), heart failure (HF) (2%) and chronic coronary syndromes (2%), although their prevalence may be underestimated.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">1,2</span></a> Given its complexity in terms of diagnosis and clinical approach, adequate management of people with CVD implies a close, effective and bidirectional communication between PHC and hospitals.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">3,4</span></a> In fact, a well-defined functional network with the different levels of care is of the utmost importance, which is only possible with the intervention and cooperation of all institutional and political structures.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Hospital referral, when judicious, facilitates the timely diagnosis and treatment of potentially serious situations, and if appropriate to local access limitations, contributes to the correct clinical prioritization, being also a tool for updating all the professionals involved.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this document, we present general guidelines for the referral of patients with cardiovascular pathologies to a cardiology hospital consultation. Additionally, suggestions are made for the initial clinical approach within PHC, with the objective of promoting a more efficient differential diagnosis and follow-up, taking into account the limitations of access of PHC to some diagnostic exams and the context of the Portuguese national referral network.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A modified Metaplan<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">6,7</span></a> methodology was used and divided into two phases: 1) in the first phase a panel of four specialists in Cardiology and 3 specialists in General and Family Medicine convened. After a presentation by the moderator, the panel discussed and defined which cardiovascular diseases were to be addressed in this document; 2) in the second phase, and based on the previous discussion, on current clinical guidelines, and on relevant scientific papers in the field, each chapter was developed by a Cardiologist and a General Practitioner (GP). Finally, the panel convened again to discuss the referral proposals, clinical approach and follow-up of these patients in the context of PHC.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Heart failure</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Definition of heart failure</span><p id="par0030" class="elsevierStylePara elsevierViewall">HF is defined as a syndrome caused by an anomalous cardiac structure and/or function, leading to a blood output that is inadequate to the metabolic requirements of the heart.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">8</span></a> HF may be asymptomatic at an early stage, with subsequent symptoms onset.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Heart failure diagnosis and classification algorithm</span><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> describes the diagnosis algorithm, including typical signs and symptoms of HF, as well as the classification of HF according to left ventricular ejection fraction (LVEF).<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par1875" class="elsevierStylePara elsevierViewall">In case of suspected HF, the diagnosis should be performed as soon as possible, ideally with evaluation of the results within a timeframe not exceeding two weeks to one month.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">11</span></a></p><p id="par1880" class="elsevierStylePara elsevierViewall">Classification of HF based on function and cardiac structural changes is shown in <a class="elsevierStyleCrossRef" href="#tbl0055">Table 1</a>.</p><elsevierMultimedia ident="tbl0055"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis - initial investigation</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Laboratory evaluation<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Complete blood count, renal, hepatic and thyroid function, lipid profile, creatine kinase, HbA1c and glycemia (described in this document as baseline laboratory evaluation);</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ferritin, % transferrin saturation ((iron/total iron-binding capacity)x100);</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Natriuretic peptides, according to <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>, if available;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Urine sediment.</p></li></ul></p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Treatment</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Approach to heart failure with reduced ejection fraction</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Non-pharmacological measures<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">12</span></a></span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Control of risk factors and lifestyle modification;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Influenza and anti-pneumococcal vaccination;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Daily weight monitoring and self-monitoring of symptoms;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Avoid the use of potential harmful medication (e.g., non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors).</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pharmacological therapy</span><p id="par0110" class="elsevierStylePara elsevierViewall">The prognostic-modifying therapy of the patient with HF should include angiotensin receptor-neprilysin inhibitors (ARNI)/angiotensin converting enzyme inhibitor (ACEi), beta blockers (BB), mineralocorticoid receptor antagonists – spironolactone or eplerenone (MRA) and sodium-glucose cotransporter 2 inhibitors – dapagliflozin or empagliflozin (SGLT2i), as soon as possible, in order to reduce mortality, hospitalizations for HF, and symptoms.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">8,10</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">∘</span><p id="par0115" class="elsevierStylePara elsevierViewall">ACEi or ARBs should be replaced by an ARNI in suitable patients (i.e., patients that remain symptomatic).</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">∘</span><p id="par0120" class="elsevierStylePara elsevierViewall">If an ACEi is to be substituted by an ARNI, the ARNI should only be initiated 36 hours after ACEi discontinuation.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">∘</span><p id="par0125" class="elsevierStylePara elsevierViewall">Initiation of dapagliflozin and empagliflozin is not recommended in patients with an eGFR <25 and <20 mL/min/1.73 m<span class="elsevierStyleSup">2</span>, respectively. In the case of dapagliflozin if the level of eGFR falls below 25 mL/min/1.73 m<span class="elsevierStyleSup">2</span> after initiation, there is no need for treatment discontinuation.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13–15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">∘</span><p id="par0130" class="elsevierStylePara elsevierViewall">ARNI/ACEi/ARBs or MRAs should be prescribed with caution for patients with an eGFR<30 ml/min.</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">In patients with signs and/or symptoms of congestion, loop diuretics, such as furosemide, are recommended to improve and reduce symptoms and enhance exercise ability.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Ivabradine should be considered in symptomatic patients with LVEF≤35% at sinus rhythm, and with a heart rate (HR) at rest of ≥70 beats per minute (bpm), despite treatment with BB or ACEi/ARB/MRA, or until evaluation by the cardiologist in case of contraindication for the use of BB.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Vericiguat and digoxin may be considered in patients with worsening HF or who remain symptomatic, respectively, after cardiological evaluation.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Devices in HF</span><p id="par0155" class="elsevierStylePara elsevierViewall">In certain patients, an implantable cardioverter-defibrillator (ICD) is recommended to reduce the risk of sudden death and all-cause mortality.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy (CRT) improves cardiac performance in selected patients, improves symptoms and well-being, and reduces morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Comorbidities</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">Anemia and/or iron deficiency</p></li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">∘</span><p id="par0175" class="elsevierStylePara elsevierViewall">Intravenous iron replacement with iron carboxymaltosis<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">∘</span><p id="par0180" class="elsevierStylePara elsevierViewall">Do not use oral replacement therapy.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0555"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">Atrial fibrillation</p></li></ul><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">∘</span><p id="par0190" class="elsevierStylePara elsevierViewall">See chapter dedicated to AF;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">∘</span><p id="par0195" class="elsevierStylePara elsevierViewall">Diltiazem or verapamil should not be used.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0560"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall">Type 2 diabetes</p></li></ul><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">∘</span><p id="par0205" class="elsevierStylePara elsevierViewall">1<span class="elsevierStyleSup">st</span> line: SGLT2i (reduction in risk of hospitalization for HF)<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">19</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">∘</span><p id="par0210" class="elsevierStylePara elsevierViewall">Metformin can be considered if the glomerular filtration rate (GFR) >30 ml/min/1.73 m<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">2,20</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">∘</span><p id="par0215" class="elsevierStylePara elsevierViewall">The use of glitazone is not recommended.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">21</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0565"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0220" class="elsevierStylePara elsevierViewall">Lung diseases</p></li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">∘</span><p id="par0225" class="elsevierStylePara elsevierViewall">Beta blockers are only relatively contraindicated in asthma, but not in chronic obstructive pulmonary disease (COPD)<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">22</span></a>;</p></li></ul><ul class="elsevierStyleList" id="lis0765"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Preferable: bisoprolol or nebivolol; carvedilol can also be used<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9,22</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">∘</span><p id="par0235" class="elsevierStylePara elsevierViewall">Inhaled corticosteroids are preferable to oral corticosteroids<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9,23</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">∘</span><p id="par0240" class="elsevierStylePara elsevierViewall">Noninvasive ventilation can be added to conventional therapy.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">9</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0575"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">Depression</p></li></ul><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">∘</span></span><p id="par0250" class="elsevierStylePara elsevierViewall">Sertraline and escitalopram can be used<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24,25</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">∘</span></span><p id="par0255" class="elsevierStylePara elsevierViewall">Tricyclic antidepressants are not recommended.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9,26</span></a></p></li></ul></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Approach to heart failure with mildly reduced ejection fraction</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">•</span><p id="par0265" class="elsevierStylePara elsevierViewall">Pharmacological therapy</p></li></ul><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">∘</span><p id="par0270" class="elsevierStylePara elsevierViewall">Loop diuretics should be used to relieve congestion<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">27</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">∘</span><p id="par0275" class="elsevierStylePara elsevierViewall">The use of ARNI, ACEi/ARB, BB and MRA can be considered to reduce the risk of hospitalization due to HF or death.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0580"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par0280" class="elsevierStylePara elsevierViewall">Identify and treat comorbidities.</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Approach to heart failure with preserved ejection fraction</span><p id="par0285" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">•</span><p id="par0290" class="elsevierStylePara elsevierViewall">Pharmacological therapy</p></li></ul><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">∘</span><p id="par0295" class="elsevierStylePara elsevierViewall">Loop diuretics should be used to relieve congestion.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">27</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0585"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par0300" class="elsevierStylePara elsevierViewall">Identify and treat comorbidities (e.g.: obesity, hypertension (HT), obstructive sleep apnea syndrome (OSAS), coronary artery disease (CAD), type 2 diabetes).<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Criteria for referral to a cardiology consultation (or internal medicine, depending on local resources)</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Heart failure with reduced or mildly reduced LVEF (≤49%)<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a></span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">∘</span><p id="par0310" class="elsevierStylePara elsevierViewall">Patients with <span class="elsevierStyleItalic">de novo</span> HF;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">∘</span><p id="par0315" class="elsevierStylePara elsevierViewall">Patients with LVEF<50%.</p></li></ul></p><p id="par0320" class="elsevierStylePara elsevierViewall">The decision of referral to a hospital consultation should not result in a delay in the initiation/optimization of prognostic-modifying therapy (see recommended therapies mentioned), which is useful for the cardiovascular protection of the patient while waiting for a hospital consultation.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Heart failure with preserved LVEF (≥50%)<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a></span><p id="par0325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">∘</span><p id="par0330" class="elsevierStylePara elsevierViewall">Patients with preserved LVEF, who have had >2 hospitalizations/visits to the emergency department (ER) in one year, after excluding non-compliance with medication and lifestyle measures;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">∘</span><p id="par0335" class="elsevierStylePara elsevierViewall">Patients with suspected restrictive/infiltrative disease (e.g., cardiac amyloidosis);</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">∘</span><p id="par0340" class="elsevierStylePara elsevierViewall">Patients with suspected hypertrophic cardiomyopathy;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">∘</span><p id="par0345" class="elsevierStylePara elsevierViewall">Patients with moderate/severe pulmonary HT.</p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Criteria for returning to primary healthcare and follow-up plan</span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Criteria for returning in heart failure with reduced or mildly reduced LVEF (≤49%)</span><p id="par0350" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">•</span><p id="par0355" class="elsevierStylePara elsevierViewall">Patients with LVEF>35%, without devices, under maximum optimized therapy, without hospitalizations/decompensation episodes >1 year, with a concluded etiological evaluation.</p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Criteria for returning in heart failure with preserved LVEF (≥50%)</span><p id="par0360" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">•</span><p id="par0365" class="elsevierStylePara elsevierViewall">Patients without indication for further investigation and without indication for specific intervention.</p></li></ul></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Heart failure follow-up plan in primary healthcare</span><p id="par0370" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">•</span><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Before</span> the hospital consultation:</p></li></ul><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">∘</span><p id="par0380" class="elsevierStylePara elsevierViewall">Clinical, analytical and electrocardiogram (ECG) reassessment when titrating disease modifying drugs;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">∘</span><p id="par0385" class="elsevierStylePara elsevierViewall">Repeat transthoracic echocardiogram (TTE) after three to six months of maximum optimized therapy.</p></li></ul><ul class="elsevierStyleList" id="lis0590"><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">•</span><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">After</span> discharge from hospital consultation:</p></li></ul><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">∘</span><p id="par0395" class="elsevierStylePara elsevierViewall">Medical consultation and laboratory reassessment every six months;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">∘</span><p id="par0400" class="elsevierStylePara elsevierViewall">Annual ECG reassessment;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">∘</span><p id="par0405" class="elsevierStylePara elsevierViewall">In case the patient's clinical condition worsens, reassess ECG and TTE.</p></li></ul><ul class="elsevierStyleList" id="lis0595"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">•</span><p id="par0410" class="elsevierStylePara elsevierViewall">In case of complications or worsening of the clinical condition, consider the possibility of contacting the referral center.</p></li></ul></p></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Hypertension</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Definition</span><p id="par0420" class="elsevierStylePara elsevierViewall">Hypertension is defined as a systolic blood pressure (SBP)≥140 mmHg and/or diastolic blood pressure (DBP)≥90 mmHg, at the doctor's office.<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">29,30</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Evaluation and risk stratification of hypertensive patients in primary healthcare</span><p id="par0425" class="elsevierStylePara elsevierViewall">Once the diagnosis of HT has been confirmed, the patients’ assessment should meet the following objectives<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">30</span></a>:<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">•</span><p id="par0430" class="elsevierStylePara elsevierViewall">Identify signs of secondary HT;</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">•</span><p id="par0435" class="elsevierStylePara elsevierViewall">Detect target organ damage;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">•</span><p id="par0440" class="elsevierStylePara elsevierViewall">Assist in cardiovascular risk stratification;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">•</span><p id="par0445" class="elsevierStylePara elsevierViewall">Assess the existence of other associated pathologies that may influence the prognosis and treatment of HT.</p></li></ul></p><p id="par0450" class="elsevierStylePara elsevierViewall">In PHC, the GP should perform a clinical history and complete objective examination, as well as request relevant tests.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">29</span></a></p><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Cardiovascular risk assessment</span><p id="par0455" class="elsevierStylePara elsevierViewall">The cardiovascular (CV) risk associated with the different HT stages is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Diagnosis</span><p id="par0460" class="elsevierStylePara elsevierViewall">Recommended exams to diagnose HT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">TREATMENT</span><p id="par0465" class="elsevierStylePara elsevierViewall">A suggested treatment algorithm for HT is presented in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Therapeutic goals (in the doctor's office)<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a>:</span><p id="par0470" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">•</span><p id="par0475" class="elsevierStylePara elsevierViewall">18–65 years:</p></li></ul><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">∘</span><p id="par0480" class="elsevierStylePara elsevierViewall">Initial goal: blood pressure (BP) <140/90 mmHg;</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">∘</span><p id="par0485" class="elsevierStylePara elsevierViewall">If well tolerated, SBP should be between 120–130 mmHg and DBP between 70<span class="elsevierStyleBold">–</span>79 mmHg;</p></li></ul><ul class="elsevierStyleList" id="lis0600"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">•</span><p id="par0490" class="elsevierStylePara elsevierViewall">>65 years:</p></li></ul><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">∘</span><p id="par0495" class="elsevierStylePara elsevierViewall">SBP 130–140 mmHg and DBP 70–79 mmHg, regardless of CVD history.</p></li></ul></p></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">When and how to refer to a hospital consultation</span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Referral criteria<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">30,31</span></a></span><p id="par0500" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">•</span><p id="par0505" class="elsevierStylePara elsevierViewall">Refractory HT (uncontrolled, with SBP>140 mmHg and/or DBP>90 mmHg, despite treatment with three antihypertensives from different drug classes at maximum tolerated doses, one of which is a diuretic);</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">•</span><p id="par0510" class="elsevierStylePara elsevierViewall">HT in young patients (<35 years);</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">•</span><p id="par0515" class="elsevierStylePara elsevierViewall">White coat HT and masked according to clinical judgment, of high and very high cardiovascular risk according to SCORE and for diagnostic clarification;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">•</span><p id="par0520" class="elsevierStylePara elsevierViewall">Suspected secondary HT, according to the following criteria:</p></li></ul><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">∘</span><p id="par0525" class="elsevierStylePara elsevierViewall">Young patients (<40 years) with grade 2 HT or onset of any degree of HT in childhood;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">∘</span><p id="par0530" class="elsevierStylePara elsevierViewall">Acute worsening of the BP profile in patients, complying with therapy, with previously documented stable normotension or severe HT (grade 3) or hypertensive emergency;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">∘</span><p id="par0535" class="elsevierStylePara elsevierViewall">Refractory HT;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">∘</span><p id="par0540" class="elsevierStylePara elsevierViewall">Presence of relevant target organ damage;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">∘</span><p id="par0545" class="elsevierStylePara elsevierViewall">Clinical or biochemical characteristics suggestive of endocrine causes of chronic kidney disease (CKD) or HT (in this context it may be important to also refer to the respective medical specialties);</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">∘</span><p id="par0550" class="elsevierStylePara elsevierViewall">Clinical features suggestive of obstructive sleep apnea (excessive daytime sleepiness, loud snoring, observed episodes of interrupted breathing during sleep, abrupt awakenings accompanied by gasping or choking, waking with a dry mouth or sore throat, morning headache, difficulty concentrating during the day);</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">∘</span><p id="par0555" class="elsevierStylePara elsevierViewall">Symptoms suggestive of pheochromocytoma or family history of pheochromocytoma.</p></li></ul></p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Follow-up plan in primary healthcare</span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Criteria for returning to PHC<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a></span><p id="par0560" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">•</span><p id="par0565" class="elsevierStylePara elsevierViewall">Properly controlled BP.</p></li></ul></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Follow-up<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a></span><p id="par0570" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">•</span><p id="par0575" class="elsevierStylePara elsevierViewall">Lifestyle modification (healthy diet and physical activity).</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">•</span><p id="par0580" class="elsevierStylePara elsevierViewall">Initial BP reduction in 1–2 weeks, which may continue to decrease over two months.</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">•</span><p id="par0585" class="elsevierStylePara elsevierViewall">Initial reassessment in the first month and follow-up dependent on the severity and comorbidities, with a maximum interval of six months (in medical and/or nursing consultation).</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">•</span><p id="par0590" class="elsevierStylePara elsevierViewall">Procedures for surveillance in general practice:</p></li></ul><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">∘</span><p id="par0595" class="elsevierStylePara elsevierViewall">Demonstrate BP control, compliance and tolerance to treatment;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">∘</span><p id="par0600" class="elsevierStylePara elsevierViewall">Assess target organ damage;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">∘</span><p id="par0605" class="elsevierStylePara elsevierViewall">Assess persistence and/or emergence of new cardiovascular risk factors;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">∘</span><p id="par0610" class="elsevierStylePara elsevierViewall">Reinforce recommendations for lifestyle changes;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">∘</span><p id="par0615" class="elsevierStylePara elsevierViewall">Regular exams:</p></li></ul><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">•</span><p id="par0620" class="elsevierStylePara elsevierViewall">Glycemia, lipid profile, uricemia, creatinine, microalbuminuria: annually.</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">•</span><p id="par0625" class="elsevierStylePara elsevierViewall">ECG every two years if the previous one is normal.</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par0630" class="elsevierStylePara elsevierViewall">Potassium: after one month of treatment and annually if the patient is treated with diuretic/ACEi/ARB/spironolactone.</p></li></ul></p></span></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Syncope</span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Definition</span><p id="par0640" class="elsevierStylePara elsevierViewall">Transient loss of consciousness due to cerebral hypoperfusion, characterized by sudden onset of short duration and spontaneous and complete recovery, accompanied by loss of postural tone<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a>;</p><p id="par1885" class="elsevierStylePara elsevierViewall">Presyncope are the signs and symptoms (dizziness, blurred vision, nausea, paleness, warmth, perspiration, others) that precede loss of consciousness in syncope<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a>;</p><p id="par1890" class="elsevierStylePara elsevierViewall">Syncope is very common in the community and 20–50% of the adult population will have at least one syncope throughout life.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Initial approach to the patient and assessment in primary health care</span><p id="par0660" class="elsevierStylePara elsevierViewall">Given the very different prognosis of the various forms of syncope, an accurate diagnosis is fundamental. After excluding other forms of non-syncope transient loss of consciousness, such as convulsion or psychogenic forms, syncope can be divided into three major etiological groups: reflex, due to orthostatic hypotension, or cardiac.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></p><p id="par1895" class="elsevierStylePara elsevierViewall">Approximately 10–20% of patients may remain without an etiological diagnosis.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">34</span></a> Up to one third of these patients will experience recurrence of syncope.<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">35</span></a></p><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Clinical history and physical examination</span><p id="par0675" class="elsevierStylePara elsevierViewall">With a careful clinical history and physical examination, which should include an orthostatic test (BP measurement in decubitus and orthostatism) and carotid sinus massage in patients over 40 years (usually performed in a hospital setting), up to 85% of all patients may have an etiological diagnosis (see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">33,36</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par1900" class="elsevierStylePara elsevierViewall">In the context of PHC, the approach in terms of initial diagnostic exams will include:<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">∘</span><p id="par0685" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation;</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">∘</span><p id="par0690" class="elsevierStylePara elsevierViewall">ECG;</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">∘</span><p id="par0695" class="elsevierStylePara elsevierViewall">24 h Holter;</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">∘</span><p id="par0700" class="elsevierStylePara elsevierViewall">TTE with Doppler study, particularly in the presence of known previous heart disease or when there are data suggestive of structural heart disease or cardiac syncope (see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>);</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">∘</span><p id="par0705" class="elsevierStylePara elsevierViewall">Stress test, if there are complaints of angina or syncope on exertion (preferably performed in a hospital setting).</p></li></ul></p><p id="par0710" class="elsevierStylePara elsevierViewall">Dizziness is also common. It is a heterogeneous symptom, including feeling dizzy (sense of motion, accompanied by nausea, vomiting, paleness and diaphoresis), presyncope (perception of an imminent episode of fainting accompanied by paleness, diaphoresis and nausea) and imbalance (loss of balance without feeling of movement).<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a> The most frequent causes include peripheral vertigo, labyrinthitis, Menière disease, central vestibular causes, psychiatric diseases, hyperventilation and multifactorial causes. The prognosis of dizziness is usually favorable, unlike that of cardiac syncope.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a></p></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">When to refer to cardiology</span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Referral criteria (cardiology consultation)</span><p id="par0715" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">•</span><p id="par0720" class="elsevierStylePara elsevierViewall">Syncope suggestive of cardiac etiology:</p></li></ul><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">∘</span><p id="par0725" class="elsevierStylePara elsevierViewall">Based on clinical criteria or after suggestive findings in diagnostic exams available in PHC (ECG, TTE, stress test, laboratory tests) (see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>);</p></li></ul><ul class="elsevierStyleList" id="lis0605"><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">•</span><p id="par0730" class="elsevierStylePara elsevierViewall">Recurrent syncope, even if of unlikely cardiac etiology;</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">•</span><p id="par0735" class="elsevierStylePara elsevierViewall">Syncope in patients with pacemakers or other devices;</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">•</span><p id="par0740" class="elsevierStylePara elsevierViewall">Syncope of unlikely cardiac etiology, but in patients with high risk professions (heavy-duty drivers, divers, etc.).</p></li></ul></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Referral criteria (emergency department)</span><p id="par0745" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">•</span><p id="par0750" class="elsevierStylePara elsevierViewall">Syncope and<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a>:</p></li></ul><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">∘</span><p id="par0755" class="elsevierStylePara elsevierViewall">Documented 2<span class="elsevierStyleSup">nd</span> or 3<span class="elsevierStyleSup">rd</span> degree AV block (ECG or Holter);</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">∘</span><p id="par0760" class="elsevierStylePara elsevierViewall">Documented alternating branch block (ECG or Holter);</p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">∘</span><p id="par0765" class="elsevierStylePara elsevierViewall">Trifascicular block (ECG or Holter);</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">∘</span><p id="par0770" class="elsevierStylePara elsevierViewall">Severe aortic stenosis;</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">∘</span><p id="par0775" class="elsevierStylePara elsevierViewall">Severe depression of left ventricular function;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">∘</span><p id="par0780" class="elsevierStylePara elsevierViewall">Severe pulmonary HT;</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">∘</span><p id="par0785" class="elsevierStylePara elsevierViewall">ICD shock;</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">∘</span><p id="par0790" class="elsevierStylePara elsevierViewall">Suspected acute coronary syndrome (ACS);</p></li><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">∘</span><p id="par0795" class="elsevierStylePara elsevierViewall">Suspected pulmonary thromboembolism;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">∘</span><p id="par0800" class="elsevierStylePara elsevierViewall">Suspected dissection of the aorta;</p></li><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">∘</span><p id="par0805" class="elsevierStylePara elsevierViewall">Traumatic brain injury.</p></li></ul></p></span></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Follow-up plan in primary health care and discharge criteria from the cardiology consultation</span><p id="par0815" class="elsevierStylePara elsevierViewall">After evaluation in an external hospital consultation (often involving neurology and psychiatry), a final diagnosis is normally achieved in approximately 80% of patients, and this will determine the therapeutic approach.<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">38</span></a></p><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Criteria for return to primary healthcare<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></span><p id="par0820" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">•</span><p id="par0825" class="elsevierStylePara elsevierViewall">Cardiac syncope:</p></li></ul><ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">∘</span><p id="par0830" class="elsevierStylePara elsevierViewall">Treated with implantable devices (follow-up at devices consultation);</p></li><li class="elsevierStyleListItem" id="lsti0655"><span class="elsevierStyleLabel">∘</span><p id="par0835" class="elsevierStylePara elsevierViewall">Treated by ablation, surgery or pharmacological control (may be discharged or followed-up in a specific consultation, depending on the situation, but only after a period of at least one year without symptoms).</p></li></ul><ul class="elsevierStyleList" id="lis0610"><li class="elsevierStyleListItem" id="lsti0660"><span class="elsevierStyleLabel">•</span><p id="par0840" class="elsevierStylePara elsevierViewall">Syncope of unknown etiology with implanted event recording device (follow-up at device consultation);</p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">•</span><p id="par0845" class="elsevierStylePara elsevierViewall">Reflex syncope without indication for pacemaker implantation and with clinical improvement after the establishment of general and/or pharmacological measures;</p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">•</span><p id="par0850" class="elsevierStylePara elsevierViewall">Syncope due to orthostatic hypotension and with clinical improvement after the establishment of general and/or pharmacological measures.</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Follow-up<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></span><p id="par0855" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0240"><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">•</span><p id="par0860" class="elsevierStylePara elsevierViewall">The therapeutic approach to most patients with syncope of non-cardiac etiology (reflex or due to orthostatic hypotension) involves reassurance, general measures and adjustment of established therapy;</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">•</span><p id="par0865" class="elsevierStylePara elsevierViewall">The follow-up is based on the evaluation of the response to these measures over time;</p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">•</span><p id="par0870" class="elsevierStylePara elsevierViewall">Patients with syncope of non-cardiac etiology (reflex or due to orthostatic hypotension) or of unknown etiology may have syncope recurrences;</p></li></ul><ul class="elsevierStyleList" id="lis0245"><li class="elsevierStyleListItem" id="lsti0690"><span class="elsevierStyleLabel">∘</span><p id="par0875" class="elsevierStylePara elsevierViewall">In these cases, the approach is summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>. Some of the approaches can be addressed in PHC.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li></ul><ul class="elsevierStyleList" id="lis0615"><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">•</span><p id="par0880" class="elsevierStylePara elsevierViewall">Patients with recurrent syncope despite the initial approach or who have begun high risk professions should be re-referred for consultation.</p></li></ul></p></span></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Valve diseases</span><p id="par0885" class="elsevierStylePara elsevierViewall">The definition and the main points in the diagnosis of valve diseases, as well as the referral criteria and follow-up plan are presented in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Chronic coronary syndromes</span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Definition</span><p id="par0890" class="elsevierStylePara elsevierViewall">Atherosclerotic CAD is a chronic progressive disease associated with a continuous high risk of long-term cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a> The risk of instability increases with insufficient control of cardiovascular risk factors, suboptimal lifestyle modifications, poor adherence to medical therapy or the presence of large areas of myocardial ischemia.<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">39,40</span></a></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Diagnosis</span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Evaluating signs and symptoms<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">41,42</span></a></span><p id="par0895" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0250"><li class="elsevierStyleListItem" id="lsti0700"><span class="elsevierStyleLabel">•</span><p id="par0900" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Typical angina</span>: presence of the three characteristics:</p></li></ul><ul class="elsevierStyleList" id="lis0255"><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">∘</span><p id="par0905" class="elsevierStylePara elsevierViewall">chest pain or discomfort (feels like pressure or squeezing);</p></li><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">∘</span><p id="par0910" class="elsevierStylePara elsevierViewall">precipitated by physical exertion;</p></li><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel">∘</span><p id="par0915" class="elsevierStylePara elsevierViewall">relieved at rest or with nitrates.</p></li></ul><ul class="elsevierStyleList" id="lis0620"><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">•</span><p id="par0920" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Atypical angina:</span> presence of two of the previous characteristics;</p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">•</span><p id="par0925" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Non-anginous chest pain:</span> presence of one or none of the previous characteristics;</p></li><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">•</span><p id="par0930" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Assess</span>: precipitating factors (severe anemia, poorly controlled HT, dysrhythmias, hyperthyroidism, smoking or contraceptive use), atherosclerotic disease in other territories (cerebral, carotid and lower limbs) and erectile dysfunction.</p></li></ul></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Initial exams<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a></span><p id="par0935" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0260"><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">•</span><p id="par0940" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation;</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">•</span><p id="par0945" class="elsevierStylePara elsevierViewall">ECG at rest;</p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">•</span><p id="par0950" class="elsevierStylePara elsevierViewall">Chest X-ray (symptoms of heart failure or lung disease);</p></li><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">•</span><p id="par0955" class="elsevierStylePara elsevierViewall">TTE.</p></li></ul></p></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Assess the pre-test probability and clinical probability of obstructive coronary artery disease<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a></span><p id="par0960" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0265"><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">•</span><p id="par0965" class="elsevierStylePara elsevierViewall">When CAD is suspected, determine the pre-test probability (PTP). PTPs of CAD according to age and to nature of symptoms are presented in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">•</span><p id="par0970" class="elsevierStylePara elsevierViewall">In patients with low PTP (5–15%), the presence of other determinants of increased risk, such as cardiovascular risk factors, changes in ECG at rest, left ventricular dysfunction, abnormal stress test and coronary calcification should be considered.</p></li></ul></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Selection of coronary artery disease diagnostic exam<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">42,43</span></a></span><p id="par0975" class="elsevierStylePara elsevierViewall">First-line exams in patients with intermediate probability (PTP>15%):<ul class="elsevierStyleList" id="lis0270"><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel">I.</span><p id="par0980" class="elsevierStylePara elsevierViewall">Non-invasive functional imaging for the determination of ischemia:</p></li></ul><ul class="elsevierStyleList" id="lis0275"><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">•</span><p id="par0985" class="elsevierStylePara elsevierViewall">Myocardial perfusion scintigraphy (MPS);</p></li><li class="elsevierStyleListItem" id="lsti0775"><span class="elsevierStyleLabel">•</span><p id="par0990" class="elsevierStylePara elsevierViewall">Stress TTE.</p></li></ul><ul class="elsevierStyleList" id="lis0625"><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">II.</span><p id="par0995" class="elsevierStylePara elsevierViewall">Anatomical evaluation with computed tomography coronary angiogram (CTCA)</p></li></ul></p><p id="par1000" class="elsevierStylePara elsevierViewall">The stress test has a low performance in the confirmation or exclusion of the disease.</p><p id="par1005" class="elsevierStylePara elsevierViewall">In the case of high clinical probability of CAD, persistence of symptoms under medical therapy, typical angina at low level of exertion or high risk of cardiovascular events – invasive coronary angiography may be indicated (refer to urgent cardiology consultation).</p></span></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Action plan in primary health care</span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Non-pharmacological measures<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">44</span></a>:</span><p id="par1010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0285"><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">•</span><p id="par1015" class="elsevierStylePara elsevierViewall">Lifestyle modification and aggressive control of all cardiovascular risk factors.</p></li></ul></p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Pharmacological measures<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">42,44</span></a>:</span><p id="par1020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0290"><li class="elsevierStyleListItem" id="lsti0800"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Anti-angina therapy:</span></p></li></ul><ul class="elsevierStyleList" id="lis0295"><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">∘</span><p id="par1030" class="elsevierStylePara elsevierViewall">1st line: BB at maximum tolerated dose (MTD);</p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">∘</span><p id="par1035" class="elsevierStylePara elsevierViewall">2nd line: CCB, ivabradine, nicorandil, ranolazine, trimetazidine and long-acting nitrates (nitroglycerin, isosorbide dinitrate and isosorbide mononitrate).</p></li></ul><ul class="elsevierStyleList" id="lis0630"><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antithrombotic therapy:</span></p></li></ul><ul class="elsevierStyleList" id="lis0300"><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel">∘</span><p id="par1045" class="elsevierStylePara elsevierViewall">Before hospital referral:</p></li></ul><ul class="elsevierStyleList" id="lis0305"><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">•</span><p id="par1050" class="elsevierStylePara elsevierViewall">If ischemia was unequivocally demonstrated and the patient has an appropriate clinical risk profile, aspirin can be started;</p></li></ul><ul class="elsevierStyleList" id="lis0635"><li class="elsevierStyleListItem" id="lsti0830"><span class="elsevierStyleLabel">∘</span><p id="par1055" class="elsevierStylePara elsevierViewall">After elective angioplasty:</p></li></ul><ul class="elsevierStyleList" id="lis0310"><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">•</span><p id="par1060" class="elsevierStylePara elsevierViewall">Aspirin (ASA) 100 and clopidogrel 75 for at least 6 months; in case of high hemorrhagic risk: 1–3 months;</p></li></ul><ul class="elsevierStyleList" id="lis0640"><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">∘</span><p id="par1065" class="elsevierStylePara elsevierViewall">After acute coronary syndrome:</p></li></ul><ul class="elsevierStyleList" id="lis0315"><li class="elsevierStyleListItem" id="lsti0845"><span class="elsevierStyleLabel">•</span><p id="par1070" class="elsevierStylePara elsevierViewall">Dual antiplatelet therapy (ASA+ticagrelor 90 mg or prasugrel 10 mg; if unavailable or contraindicated, clopidogrel);</p></li></ul><ul class="elsevierStyleList" id="lis0645"><li class="elsevierStyleListItem" id="lsti0850"><span class="elsevierStyleLabel">•</span><p id="par1075" class="elsevierStylePara elsevierViewall">For at least 12 months;</p></li><li class="elsevierStyleListItem" id="lsti0855"><span class="elsevierStyleLabel">•</span><p id="par1080" class="elsevierStylePara elsevierViewall">Long-term extension with ticagrelor 60 mg in patients at high (IIa) or moderate (IIb) risk of ischemic events: diffuse multivessel CAD associated with comorbidities (diabetes, recurrent myocardial infarction (MI), peripheral artery disease, or CKD), without high hemorrhagic risk and who tolerate dual antiplatelet therapy during the first year;</p></li><li class="elsevierStyleListItem" id="lsti0860"><span class="elsevierStyleLabel">•</span><p id="par1085" class="elsevierStylePara elsevierViewall">Alternatively to DAPT, may consider intensification with rivaroxaban 2.5 mg therapy in combination with aspirin in patients who had an myocardial infarction at least one year before or in cases of CCS with multivessel CAD;</p></li></ul><ul class="elsevierStyleList" id="lis0650"><li class="elsevierStyleListItem" id="lsti0865"><span class="elsevierStyleLabel">•</span><p id="par1090" class="elsevierStylePara elsevierViewall">In patients with indication for long-term oral anticoagulation therapy (AF):</p></li></ul><ul class="elsevierStyleList" id="lis0655"><li class="elsevierStyleListItem" id="lsti0870"><span class="elsevierStyleLabel">∘</span><p id="par1095" class="elsevierStylePara elsevierViewall">Hospitalization: Aspirin+clopidogrel+anticoagulant;</p></li><li class="elsevierStyleListItem" id="lsti0875"><span class="elsevierStyleLabel">∘</span><p id="par1100" class="elsevierStylePara elsevierViewall">First year: Clopidogrel+oral anticoagulant (direct oral anticoagulant (DOAC));</p></li><li class="elsevierStyleListItem" id="lsti0880"><span class="elsevierStyleLabel">∘</span><p id="par1105" class="elsevierStylePara elsevierViewall">>12 months: oral anticoagulant (DOAC).</p></li></ul><ul class="elsevierStyleList" id="lis0660"><li class="elsevierStyleListItem" id="lsti0885"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Hypolipemic therapy:</span></p></li></ul><ul class="elsevierStyleList" id="lis0320"><li class="elsevierStyleListItem" id="lsti0890"><span class="elsevierStyleLabel">∘</span><p id="par1115" class="elsevierStylePara elsevierViewall">Therapeutic goals:</p></li></ul><ul class="elsevierStyleList" id="lis0325"><li class="elsevierStyleListItem" id="lsti0895"><span class="elsevierStyleLabel">•</span><p id="par1120" class="elsevierStylePara elsevierViewall">LDL-c<55 mg/dL and reduction of at least 50% relative to baseline;</p></li><li class="elsevierStyleListItem" id="lsti0900"><span class="elsevierStyleLabel">•</span><p id="par1125" class="elsevierStylePara elsevierViewall">In the presence of second event within two years: LDL-c<40 mg/dL;</p></li></ul><ul class="elsevierStyleList" id="lis0665"><li class="elsevierStyleListItem" id="lsti0905"><span class="elsevierStyleLabel">∘</span><p id="par1130" class="elsevierStylePara elsevierViewall">Recommended drugs: statins at MTD, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) (available at hospital level)</p></li></ul><ul class="elsevierStyleList" id="lis0670"><li class="elsevierStyleListItem" id="lsti0910"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antihypertensive therapy:</span></p></li></ul><ul class="elsevierStyleList" id="lis0330"><li class="elsevierStyleListItem" id="lsti0915"><span class="elsevierStyleLabel">∘</span><p id="par1140" class="elsevierStylePara elsevierViewall">Therapeutic goal: BP<130 mmHg, if tolerated;</p></li><li class="elsevierStyleListItem" id="lsti0920"><span class="elsevierStyleLabel">∘</span><p id="par1145" class="elsevierStylePara elsevierViewall">Recommended drugs: BB and/or ACEi; if necessary add other drugs;</p></li></ul><ul class="elsevierStyleList" id="lis0675"><li class="elsevierStyleListItem" id="lsti0925"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antidiabetic therapy:</span></p></li></ul><ul class="elsevierStyleList" id="lis0335"><li class="elsevierStyleListItem" id="lsti0930"><span class="elsevierStyleLabel">∘</span><p id="par1155" class="elsevierStylePara elsevierViewall">1<span class="elsevierStyleSup">st</span> line: SGLT2i and GLP-1 analogues, due to their impact on the reduction of CV events.</p></li></ul></p></span></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">When and how to refer to cardiology</span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Referral criteria</span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">Referral to the emergency department<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a>:</span><p id="par1160" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0340"><li class="elsevierStyleListItem" id="lsti0935"><span class="elsevierStyleLabel">•</span><p id="par1165" class="elsevierStylePara elsevierViewall">Suspected ACS;</p></li></ul></p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Referral for cardiology consultation:</span><p id="par1170" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0345"><li class="elsevierStyleListItem" id="lsti0940"><span class="elsevierStyleLabel">•</span><p id="par1175" class="elsevierStylePara elsevierViewall">Initial clinical evaluation suggestive of high risk events:</p></li></ul><ul class="elsevierStyleList" id="lis0350"><li class="elsevierStyleListItem" id="lsti0945"><span class="elsevierStyleLabel">∘</span><p id="par1180" class="elsevierStylePara elsevierViewall">High clinical probability of CAD;</p></li><li class="elsevierStyleListItem" id="lsti0950"><span class="elsevierStyleLabel">∘</span><p id="par1185" class="elsevierStylePara elsevierViewall">Persistence of symptoms under optimized medical therapy;</p></li><li class="elsevierStyleListItem" id="lsti0955"><span class="elsevierStyleLabel">∘</span><p id="par1190" class="elsevierStylePara elsevierViewall">Typical angina at low level of exertion (in the context of daily life activities);</p></li><li class="elsevierStyleListItem" id="lsti0960"><span class="elsevierStyleLabel">∘</span><p id="par1195" class="elsevierStylePara elsevierViewall">Carotid disease or symptomatic peripheral artery disease in patients with ischemic cardiopathy;</p></li></ul><ul class="elsevierStyleList" id="lis0680"><li class="elsevierStyleListItem" id="lsti0965"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1200" class="elsevierStylePara elsevierViewall">Significant <span class="elsevierStyleItalic">de novo</span> ischemia (MPS with ischemic area ≥10% of the myocardium);</p></li><li class="elsevierStyleListItem" id="lsti0970"><span class="elsevierStyleLabel">•</span><p id="par1205" class="elsevierStylePara elsevierViewall">Significant lesions in CTCA (CAD RADS >3: severe coronary stenosis [70-99%)], left main >50% or 3-vessel obstructive [≥70%] disease, total coronary occlusion [100%]).</p></li><li class="elsevierStyleListItem" id="lsti0975"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">•</span></span><p id="par1210" class="elsevierStylePara elsevierViewall">Left ventricular dysfunction (LVEF<50%).</p></li></ul></p></span></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Important information to be included in the consultation request</span><p id="par1215" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0355"><li class="elsevierStyleListItem" id="lsti0980"><span class="elsevierStyleLabel">•</span><p id="par1220" class="elsevierStylePara elsevierViewall">Signs, symptoms, cardiovascular risk factors and comorbidities;</p></li><li class="elsevierStyleListItem" id="lsti0985"><span class="elsevierStyleLabel">•</span><p id="par1225" class="elsevierStylePara elsevierViewall">Results of exams;</p></li><li class="elsevierStyleListItem" id="lsti0990"><span class="elsevierStyleLabel">•</span><p id="par1230" class="elsevierStylePara elsevierViewall">Response to established therapy.</p></li></ul></p></span></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Follow-up plan in primary healthcare</span><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">Criteria of return to PHC</span><p id="par1235" class="elsevierStylePara elsevierViewall">Patients with controlled cardiovascular symptoms and risk factors after diagnosis and therapeutic optimization by a cardiologist.</p></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Follow-up</span><p id="par1240" class="elsevierStylePara elsevierViewall">After initial diagnosis or CV event, consultation at three and six months, annually thereafter<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a>:<ul class="elsevierStyleList" id="lis0360"><li class="elsevierStyleListItem" id="lsti0995"><span class="elsevierStyleLabel">•</span><p id="par1245" class="elsevierStylePara elsevierViewall">Clinical evaluation, lifestyle modification, cardiovascular RF control and adherence to therapy;</p></li><li class="elsevierStyleListItem" id="lsti1000"><span class="elsevierStyleLabel">•</span><p id="par1250" class="elsevierStylePara elsevierViewall">Routine exams:</p></li></ul><ul class="elsevierStyleList" id="lis0365"><li class="elsevierStyleListItem" id="lsti1005"><span class="elsevierStyleLabel">•</span><p id="par1255" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation;</p></li><li class="elsevierStyleListItem" id="lsti1010"><span class="elsevierStyleLabel">•</span><p id="par1260" class="elsevierStylePara elsevierViewall">ECG at rest;</p></li></ul><ul class="elsevierStyleList" id="lis0685"><li class="elsevierStyleListItem" id="lsti1015"><span class="elsevierStyleLabel">•</span><p id="par1265" class="elsevierStylePara elsevierViewall">TTE: 1 year (if previously abnormal) or periodically (every 3–5 years);</p></li><li class="elsevierStyleListItem" id="lsti1020"><span class="elsevierStyleLabel">•</span><p id="par1270" class="elsevierStylePara elsevierViewall">Non-invasive imaging exam: change in the level of symptoms or periodically (every 3-5 years) for ischemia assessment.</p></li></ul></p></span></span></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Arrhythmias and palpitations</span><span id="sec0330" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0350">Definition</span><p id="par1275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Bradycardia</span> is characterized by a HR <60 bpm and can be caused by a dysfunction in the sinus node, an atrioventricular block or a block in conduction. <span class="elsevierStyleBold">Tachycardia</span> is characterized by a HR >100 bpm and can be ventricular or supraventricular.</p><p id="par1280" class="elsevierStylePara elsevierViewall">Palpitations result from an unconfortable perception of the heartbeat by the patient. Two types of palpitations are identified:<ul class="elsevierStyleList" id="lis0370"><li class="elsevierStyleListItem" id="lsti1025"><span class="elsevierStyleLabel">•</span><p id="par1285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Normal palpitations</span> – they occur due to exercise, emotion, stress, or after ingestion of substances that increase adrenergic activity or decrease vagal activity;</p></li><li class="elsevierStyleListItem" id="lsti1030"><span class="elsevierStyleLabel">•</span><p id="par1290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Abnormal palpitations</span> – they occur for no reason and can be fast or strong/slow. These palpitations may indicate cardiac arrhythmia. However, most people who have electrical conduction disturbances experience syncope, and chest pain, rather than palpitations.<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">45–49</span></a></p></li></ul></p></span><span id="sec0335" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0355">Differential diagnosis</span><span id="sec0340" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0360">Exams to be requested in an outpatient context</span><span id="sec0345" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0365">Laboratory evaluation:</span><p id="par1295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0375"><li class="elsevierStyleListItem" id="lsti1035"><span class="elsevierStyleLabel">•</span><p id="par1300" class="elsevierStylePara elsevierViewall">Baseline laboratory assessment plus evaluation of the thyroid function and of potassium and magnesium levels<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a>;</p></li></ul></p></span><span id="sec0350" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0370">ECG at rest and Holter:</span><p id="par1305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0380"><li class="elsevierStyleListItem" id="lsti1040"><span class="elsevierStyleLabel">•</span><p id="par1310" class="elsevierStylePara elsevierViewall">Immediate electrocardiographic monitoring if arrhythmic syncope is suspected.<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50,51</span></a></p></li></ul></p></span><span id="sec0355" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0375">Treadmill stress test to assess chronotropic incompetence or onset of conduction disorders on exertion<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50,52</span></a>;</span><span id="sec0360" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0380">Refer to TTE:</span><p id="par1315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0385"><li class="elsevierStyleListItem" id="lsti1045"><span class="elsevierStyleLabel">•</span><p id="par1320" class="elsevierStylePara elsevierViewall">If there is known previous heart disease or when data are suggestive of structural and functional left ventricular (LV) heart disease.<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50,53</span></a></p></li></ul></p></span></span></span></span><span id="sec0365" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0385">Action plan in primary health care</span><span id="sec0370" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0390">Non-pharmacological and pharmacological treatment</span><p id="par1325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0390"><li class="elsevierStyleListItem" i