cardiology coronary artery disease or
TRANSCRIPT
Cardiology
Coronary Artery DiseaseOr Coronary heart DiseaseOrIscheamic heart Disease
Coronary Artery Disease
Angina
Myocardial Infarction (MI) or Heart Attack
(cardiac failure)
Coronary Artery Disease
Leading cause of death in the UK
However, as in most western countries, mortality from CAD is falling in the UK
Process of CAD
Arteriosclerosis- ageing process that begins in youth
It involves the deposition of various substances, principally lipids, in the inner layer of the blood vessels- leads to fatty plagues, that protrude into the lumen of the vessel
70% narrowing – symptoms evident
CAD
Atherosclerosis Partially occluding the lumen Decreased blood supply to the muscle
Arteriosclerosis Hardening of the arteries.
(refer to your package on PVD)
Risk Factors
Smoking Hypertension Lack of exercise Hyperlipodaemia Stress Obesity/diet
Risk factors
Diabetes Family History Gender Age Social class?
Angina
Where the demand for oxygen by the heart muscle is not met –ischeamia
Chest Pain/tightness Central Referred down the arm, pain, heaviness Brought on by effort Eased by rest Exacerbated by eating ‘heavy meals’, cold
weather, emotional disturbance Associated with SOB
Diagnosis of Angina
History
ECG changes
Exercise Test –to establish the extent and severity of CAD
Angina management
Medical management- to increase oxygen supply or decrease the demand for oxygen
Drug therapy Antiplatelet Nitrates Beta blockers Calcium antagonists
Angina management
Alter lifestyle- decrease risk profile
Surgery –CABG
Angioplasty PTCA
Cardiac rehabilitation –physio involvement
Myocardial Infarction
Atherosclerotic plague ruptures and haemorrhages-leading to clot formation and complete occlusion of the vessels lumen
If the cardiac muscle is deprived of blood supply-tissue death – infarction
Severity and consequences depend on where the blockage occurs
MI-Typical presentation
Central chest pain, tightness, crushing Radiates down arms, into neck or jaw
or abdomen Patient often describes a severe bout
of indigestion Sudden, progressive Not relieved by GTN SOB, sweating,faint,weakness,nausea
Medical management
Admit to hospital ASAP Rapid assessment
History ECG-12 lead Serum enzymes or Troponin levels
Thrombolytic therapy – streptokinase
Pain management - diamorphine
Management in Hospital
Rest with progressive activity If uncomplicated MI
Sit out in 48 hours Home 5-7 days Mobilise around house first week Short walks second week at home 4-6 weeks post MI start cardiac
rehabilition.
Management in Hospital
Complicated MIs have longer in hospital Complications
LVF Further chest pain Arrhymias Conduction defects Social circumstances Cardiac arrest Pericarditis PE Psychological problems
Cardiac rehabilitation
Aim Facilitate physical, psychological
and emotional recovery to enable patients to achieve and maintain better health
Goals – to improve secondary prevention and improve Q of L.
Four Phases of cardiac rehab
Phase one – inpatient, activity to counteract bed rest and start adjustment to condition and education
Phase two – period between hospital and home reinforce behaviour changes
Phase three – issues address in the rest of this talk
Phase four – long term maintance phase, self exercise or community programme
Standard proposed by the National Service Framework NSF
Every hospital should ensure that 85% of people discharged from hospital with a primary diagnosis of acute MI or coronary revascularisation are offered cardiac rehabilitation
Comprehensive programme /or exercise alone
Systematic review Heart disease is a multi factorial
disease Many problems are experienced by
people with heart disease not only physical problems but anxiety, and misconceptions about there health
Changes to a healthy lifestyle are important
Comprehensive programme
A combination of the following Exercise
Education
Psychological help
Structure of the programme
Great variation in delivery
Hospital based Outpatient programme Twice a week 6-10 weeks Low risk patients
Multi-professional approach
Needed due to multi-factorial nature of coronary heart disease
Physiotherapist Nursing staff Dietician OT Clinical psychologist Physician Social worker Pharmacist
Who benefits
Post MI Post CABG Heart failure PTCA ICD Angina Heart Transplant
Result of Research
Promotes recovery, physical fitness and psychological
Maintain better health Reduce the risk of death Positive effect on lipid profile, BP
and smoking cessation
Research
However, most of the research has been on white middle class males
? Can we generalize to others
Women
Fewer take up exercise based programmes
More women drop out When women do attend their
outcomes are equal to males
Age
10% are over 75 years Response to exercise similar to
younger patients Decrease in re hospitalisation
Ethnic minorities
People from the Indian subcontinent have a higher mortality
No different response to rehab However low attendance rates to
programme
Role of deprivation
Uptake and completion were found to be low among the lower socio-economic groups
Studies on inequalities of health have shown that individuals in lower classes have a higher death rate ?related to smoking and diet or uptake
of treatment
Drop outs
High Intensity programmes Poorly organised programmes Access problems More than one MI Smokers
Strategies for targeting the underrepresented groups
More gender specific information. Housework activities and exercise)
Peer support at an early stage Programme characteristics that
allow more flexibility and choice to meet patients needs, lower intensity programmes
Strategies for targeting the underrepresented groups
Environmental factors – physical accessibility flexible working hours and assistance with transport
Patients characteristics individual attention rather than group , variety of media, educational material and method of delivery
Some evidence that the inclusion of partners and other close family members effects outcome