The Complete Doctor Academy · AKT  Cardiovascular NICE Guidelines, broken into bites
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Deck 3 · Cardiovascular NICE guidelines · teach-then-check

NICE, in bite-size boxes

Each guideline is broken into small boxes — one idea each. Read the box, then answer the quick check underneath. Tap Show answer to mark yourself.

NG136
Hypertension in adults
NICE NG136 — confirm current version at nice.org.uk
💡Core conceptThe big idea
  • High blood pressure is usually silent but steadily damages arteries, heart, brain and kidneys.
  • We treat numbers plus overall cardiovascular risk — not the reading alone.
? Quick check
True or false: a single high clinic reading is enough to diagnose hypertension.
Show answer
False — confirm with ABPM or home readings (HBPM) before labelling anyone hypertensive.
⚡The ruleDiagnosis & staging
  • Clinic ≥140/90 → offer ABPM/HBPM to confirm.
  • Stage 1 = ABPM ≥135/85. Stage 2 = ABPM ≥150/95.
? Quick check
A clinic BP is 146/92. What is the next step?
Show answer
Arrange ABPM (or HBPM) to confirm the diagnosis before starting treatment.
🧠How to picture itWho gets which first drug
  • Under 55 & not African/Caribbean, OR any age with T2DM → start A (ACE inhibitor / ARB).
  • 55+ OR African/Caribbean (no T2DM) → start C (calcium-channel blocker).
? Quick check
A 62-year-old of African-Caribbean origin, no diabetes. First drug?
Show answer
A calcium-channel blocker (C) — e.g. amlodipine.
⚡The ruleStepping up
  • Step 2: A + C. Step 3: A + C + D (thiazide-like diuretic, e.g. indapamide).
  • Step 4 (resistant): if K⁺ ≤4.5 add spironolactone; if K⁺ >4.5 add an alpha- or beta-blocker.
? Quick check
On A+C+D, still high, K⁺ 4.2. What do you add?
Show answer
Low-dose spironolactone (potassium is ≤4.5).
🎯Why it mattersTargets that matter
  • Under 80: clinic <140/90, ABPM <135/85.
  • 80+: clinic <150/90. T2DM with raised ACR: <130/80.
? Quick check
An 82-year-old's clinic target BP is?
Show answer
Below 150/90 (ABPM <145/85).
🧠How to picture itConfirming & measuring
  • Clinic ≥140/90 → confirm with ABPM (or HBPM) before diagnosing.
  • Check both arms; use the higher reading. Look for end-organ damage (ACR, ECG, fundi).
? Quick check
Clinic BP is 150/95 — next step before labelling hypertension?
Show answer
Offer ABPM (or HBPM) to confirm.
⚡The ruleStep 4 (resistant) rule
  • On A+C+D and still high → check adherence, then add by potassium:
  • K⁺ ≤4.5 → spironolactone; K⁺ >4.5 → alpha- or beta-blocker.
? Quick check
Resistant hypertension, K⁺ 4.2 — what to add?
Show answer
Low-dose spironolactone.
🎯Why it mattersSevere hypertension
  • ≥180/120 with no symptoms → treat and confirm with ABPM.
  • With papilloedema, chest pain, AKI or new neuro signs → same-day specialist.
? Quick check
BP 190/125 with new visual blurring and papilloedema — action?
Show answer
Same-day emergency assessment (accelerated hypertension).
NG196
Atrial fibrillation
NICE NG196 (2021, updated) — confirm at nice.org.uk
💡Core conceptThe big idea
  • AF is an irregularly irregular rhythm where the atria quiver instead of contracting.
  • The danger is clot formation → stroke, so the priority is stroke prevention, then rate/rhythm.
? Quick check
What is the main long-term risk that drives AF management?
Show answer
Stroke from atrial clot — which is why anticoagulation comes first.
⚡The ruleWho to anticoagulate
  • Score stroke risk with CHA₂DS₂-VASc.
  • Anticoagulate if ≥2 (men) or ≥3 (women). Assess bleeding risk with ORBIT.
? Quick check
A man with CHA₂DS₂-VASc of 2 — anticoagulate?
Show answer
Yes. Offer anticoagulation; a DOAC is first-line.
🧠How to picture itWhich anticoagulant
  • DOAC first-line (apixaban, rivaroxaban, edoxaban, dabigatran).
  • Warfarin only for mechanical valves or moderate–severe mitral stenosis. Aspirin has no role.
? Quick check
Patient with a mechanical heart valve and AF — DOAC or warfarin?
Show answer
Warfarin — DOACs are contraindicated in mechanical valves.
🎯Why it mattersRate vs rhythm
  • Usually rate control first (beta-blocker or rate-limiting CCB).
  • Lenient target <110 if asymptomatic; aim tighter only if symptoms persist.
? Quick check
Asymptomatic AF, resting HR 96, normal heart. Change treatment?
Show answer
No — lenient rate control (<110) is acceptable.
🧠How to picture itScore before you anticoagulate
  • CHA₂DS₂-VASc for stroke risk; ORBIT for bleeding risk.
  • Anticoagulate if score ≥2 (men) / ≥3 (women); don’t withhold for a high bleeding score alone.
? Quick check
Which score now replaces HAS-BLED for bleeding risk in NG196?
Show answer
ORBIT.
🎯Why it mattersDOAC dosing trap
  • Reduce apixaban to 2.5 mg BD if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133.
  • Avoid DOACs in mechanical valves / moderate-severe mitral stenosis — use warfarin.
? Quick check
Which valve situation needs warfarin, not a DOAC?
Show answer
Mechanical valve (and moderate–severe mitral stenosis).
⚡The ruleBleeding risk: ORBIT (and HAS-BLED)
  • NICE NG196 now uses the ORBIT score for bleeding risk (it outperformed HAS-BLED).
  • HAS-BLED (Hypertension, Abnormal renal/liver, Stroke, Bleeding, Labile INR, Elderly, Drugs/alcohol) is still widely known and used elsewhere — recognise it, but NICE prefers ORBIT.
  • A high bleeding score is not a reason to withhold anticoagulation — it prompts you to correct modifiable factors (BP, alcohol, NSAIDs).
? Quick check
Which bleeding-risk score does NICE NG196 now recommend for AF, and what replaced it?
Show answer
ORBIT is now recommended; it replaced HAS-BLED. A high score modifies risk factors, it doesn’t stop anticoagulation.
NG106
Chronic heart failure
NICE NG106 — four pillars for HFrEF; confirm at nice.org.uk
💡Core conceptThe big idea
  • Heart failure = the heart can't pump enough for the body's needs; fluid backs up (breathlessness, oedema).
  • Split by pump function: HFrEF (reduced EF) vs HFpEF (preserved EF).
? Quick check
What does 'HFrEF' stand for?
Show answer
Heart Failure with reduced Ejection Fraction.
⚡The ruleDiagnosing with NT-proBNP
  • >2000 ng/L → specialist + echo within 2 weeks.
  • 400–2000 ng/L → specialist + echo within 6 weeks. <400 makes HF unlikely.
? Quick check
NT-proBNP is 2400 ng/L. How urgently is echo needed?
Show answer
Within 2 weeks (it exceeds 2000).
🧠How to picture itThe four pillars (HFrEF)
  • Start all four: ACEi/ARNI + beta-blocker + MRA + SGLT2 inhibitor.
  • Think of a table needing four legs to stay stable — each drug cuts mortality.
? Quick check
Name the fourth pillar added in recent guidance.
Show answer
An SGLT2 inhibitor (dapagliflozin or empagliflozin).
🎯Why it mattersReal-world caution
  • Start beta-blockers low and slow, never during acute decompensation.
  • SGLT2 inhibitors now help HFpEF too (reduce hospitalisation).
? Quick check
Can you start a beta-blocker while a patient is acutely fluid-overloaded?
Show answer
No — wait until stable; start low and titrate slowly.
⚡The ruleStart low, go slow
  • Begin beta-blockers at low dose (bisoprolol 1.25 mg) and titrate.
  • Never start a beta-blocker during acute decompensation.
? Quick check
Can you start a beta-blocker in acute fluid overload?
Show answer
No — wait until stable.
🎯Why it mattersHFpEF & devices
  • SGLT2 inhibitors now reduce hospitalisation in HFpEF too.
  • Consider CRT/ICD referral in selected HFrEF with broad QRS or low EF.
? Quick check
Which drug class helps HFpEF outcomes?
Show answer
SGLT2 inhibitors.
NG238
Lipids & CVD prevention
NICE NG238 (published Dec 2023, replaced CG181)
💡Core conceptThe big idea
  • Lowering cholesterol lowers heart-attack and stroke risk.
  • Decisions use QRISK3 (10-year risk) for primary prevention, and disease status for secondary.
? Quick check
Which tool estimates 10-year CVD risk for primary prevention?
Show answer
QRISK3.
⚡The ruleWhich statin dose
  • Primary prevention, QRISK3 ≥10% → atorvastatin 20 mg.
  • Secondary prevention (known CVD) → atorvastatin 80 mg.
? Quick check
Post-MI patient — what statin dose?
Show answer
Atorvastatin 80 mg (secondary prevention).
🎯Why it mattersCheck it's working
  • Recheck lipids at 2–3 months; aim for >40% fall in non-HDL.
  • Not met and adherent → uptitrate; then add ezetimibe, then PCSK9i/inclisiran.
? Quick check
Non-HDL fell only 25% at 3 months on 20 mg, adherent. Next?
Show answer
Increase the statin dose (target >40% reduction).
🧠How to picture itWho to offer a statin
  • QRISK3 ≥10% over 10 years → offer atorvastatin 20 mg.
  • Type 1 diabetes, CKD, or familial hypercholesterolaemia → treat regardless of QRISK.
? Quick check
A 55-year-old with QRISK3 14% — statin?
Show answer
Yes — atorvastatin 20 mg (primary prevention).
⚡The ruleMonitoring on statins
  • Recheck lipids at 2–3 months (target >40% non-HDL fall) and LFTs.
  • Stop if CK ≥5× ULN with symptoms (or ≥10× ULN); LFTs stop if >3× ULN.
? Quick check
Non-HDL fell 25% at 3 months, adherent — action?
Show answer
Uptitrate the statin (target >40% reduction).
🎯Why it mattersFamilial hypercholesterolaemia
  • Suspect if total cholesterol >7.5 or premature CVD/tendon xanthomata.
  • Refer to a lipid clinic; cascade-test relatives.
? Quick check
Cholesterol 9.0 with tendon xanthomata — likely diagnosis?
Show answer
Familial hypercholesterolaemia — refer to lipid clinic.
CG95
Recent-onset chest pain & ACS
Chest pain: NICE CG95 · acute coronary syndromes: NICE NG185 (2020)
💡Core conceptThe big idea
  • Typical angina = constricting chest pain, brought on by exertion, relieved by rest/GTN in ~5 min.
  • All three features = typical; two = atypical; one/none = non-anginal.
? Quick check
Pain on exertion, eased by rest in 3 minutes, tight in nature. How many typical features?
Show answer
All three — this is typical angina.
⚡The ruleFirst-line test
  • Investigate suspected stable angina with CT coronary angiography (CTCA) first-line.
  • The old exercise ECG is no longer recommended for diagnosis.
? Quick check
Which is first-line: exercise ECG or CTCA?
Show answer
CTCA (CT coronary angiography).
🎯Why it mattersEmergency vs stable
  • Ongoing rest pain / ST elevation = STEMI → 999, primary PCI.
  • Stable exertional pattern → refer to rapid-access chest pain clinic.
? Quick check
Rest pain for 2 hours with ST elevation — action?
Show answer
Call 999 for primary PCI (this is a STEMI).
⚡The rulePost-ACS drugs
  • Dual antiplatelet therapy ~12 months, then aspirin lifelong.
  • Add ACE inhibitor, beta-blocker and high-intensity statin; offer cardiac rehab.
? Quick check
How long is dual antiplatelet therapy usually continued after ACS?
Show answer
About 12 months, then aspirin alone.
🎯Why it mattersAngina drug ladder
  • First-line: beta-blocker or calcium-channel blocker.
  • Then combine; add long-acting nitrate/ivabradine/nicorandil/ranolazine.
? Quick check
First-line anti-anginal options?
Show answer
A beta-blocker or a calcium-channel blocker.
NG158
VTE — DVT & PE
NICE NG158 — confirm current version at nice.org.uk
💡Core conceptThe big idea
  • Venous clots form in leg veins (DVT) and can travel to the lungs (PE).
  • Use the Wells score to decide whether to image or D-dimer first.
? Quick check
Which score guides whether DVT/PE is 'likely'?
Show answer
The two-level Wells score.
⚡The ruleInvestigate
  • DVT Wells ≥2 → proximal leg vein ultrasound within 4 h (≤1 → D-dimer).
  • PE Wells >4 → CTPA (V/Q if pregnant/renal); ≤4 → D-dimer.
? Quick check
Wells DVT score of 3 — image or D-dimer?
Show answer
Ultrasound within 4 hours (score ≥2 = likely).
🎯Why it mattersTreat
  • Apixaban or rivaroxaban first-line for confirmed DVT/PE.
  • Duration: 3 months provoked; ≥3–6 unprovoked; indefinite if cancer/recurrent.
? Quick check
First-line drug for a confirmed DVT with no cancer?
Show answer
Apixaban or rivaroxaban (a DOAC).
⚡The ruleDuration of anticoagulation
  • Provoked VTE: 3 months. Unprovoked: ≥3–6 months.
  • Cancer-associated or recurrent: long-term.
? Quick check
Provoked DVT after surgery — how long to anticoagulate?
Show answer
3 months.
🎯Why it mattersInvestigating unprovoked VTE
  • Don’t do routine CT abdomen/pelvis; do history, exam, bloods, CXR, urinalysis.
  • Consider antiphospholipid testing in unprovoked VTE.
? Quick check
Routine whole-body CT for unprovoked VTE — recommended?
Show answer
No — targeted assessment only.
NG147
Peripheral arterial disease
NICE NG147 — confirm current version at nice.org.uk
💡Core conceptThe big idea
  • Narrowed leg arteries cause claudication — calf pain on walking, relieved by rest.
  • Confirm with ABPI (0.5–0.9 in PAD).
? Quick check
What ABPI range suggests peripheral arterial disease?
Show answer
About 0.5–0.9 (lower = more severe).
⚡The ruleManage
  • Supervised exercise programme + atorvastatin 80 mg + clopidogrel 75 mg.
  • Clopidogrel is first-line antiplatelet in PAD (over aspirin).
? Quick check
First-line antiplatelet in PAD?
Show answer
Clopidogrel 75 mg.
🎯Why it mattersRed flag
  • Rest pain, ulcers/gangrene, ABPI <0.4 = critical limb ischaemia.
  • This is a limb emergency → urgent vascular referral.
? Quick check
Night rest pain relieved by hanging the foot out of bed, ABPI 0.3 — diagnosis?
Show answer
Critical limb ischaemia — refer urgently to vascular surgery.
🧠How to picture itConfirm with ABPI
  • Claudication + ABPI 0.5–0.9 = PAD; <0.4 suggests critical ischaemia.
  • Falsely high ABPI (>1.3) in diabetes/calcified vessels.
? Quick check
ABPI 0.7 with calf claudication — diagnosis?
Show answer
Peripheral arterial disease.
⚡The ruleBest medical therapy
  • Supervised exercise, stop smoking, atorvastatin 80 mg, clopidogrel 75 mg.
  • Manage diabetes and blood pressure aggressively.
? Quick check
First-line antiplatelet in PAD?
Show answer
Clopidogrel.
CG64
Endocarditis prophylaxis
IE prophylaxis not routine — confirm current NICE guidance
💡Core conceptThe big idea
  • Antibiotics before dental work were once routine to prevent infective endocarditis.
  • NICE changed this: routine prophylaxis is not recommended.
? Quick check
Does a prosthetic-valve patient routinely need antibiotics before a filling?
Show answer
No — routine antibiotic prophylaxis is not recommended; emphasise oral hygiene.
🎯Why it mattersWhat still matters
  • Focus on good oral hygiene and prompt treatment of infection.
  • Highest-risk patients undergoing invasive dental work may be discussed individually.
? Quick check
What is the main preventive measure now emphasised?
Show answer
Good oral hygiene (not routine antibiotics).
🧠How to picture itRecognising endocarditis
  • Fever + new murmur; splinter haemorrhages, Osler’s nodes, Janeway lesions, Roth spots.
  • IVDU/acute → *Staph aureus*; subacute → *Strep viridans*.
? Quick check
Fever, new murmur and splinter haemorrhages — diagnosis to exclude?
Show answer
Infective endocarditis.
🎯Why it mattersA colorectal clue
  • *Strep bovis/gallolyticus* endocarditis is linked to colorectal cancer.
  • Arrange colonoscopy in these patients.
? Quick check
Strep bovis endocarditis — what extra investigation?
Show answer
Colonoscopy (colorectal cancer link).