Download - Ischaemic Heart Disease for the GP
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Ischaemic Heart Disease for the GP
Chris TraceyGPVTS
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What is Ischaemic Heart Disease?
• Artherosclerotic build-up• Preventing perfusion to myocardium
• Spectrum....
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Ischaemic Spectrum
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Epidemiology
• Cardiovascular disease deaths 240,000 (2004)• IHD deaths 117,000 (2004)
• Mortality decreasing• Incidence stable
• Cost £1.7 billion in healthcare alone
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Risk Factors
• Split into Modifiable and Non-Modifiable
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Non-Modifiable
• Increasing age
• Male Gender
• Family Hx
• Ethnic Origin
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Modifiable
• Smoking• Hypertension• Dyslipidemia• Diabetes Mellitus• Obesity• High Calorie Diet• Physical Activity
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Why is this important?
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• Risk Stratification
• Primary (and Secondary) Prevention
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Risk Stratification
• Identifies risks
• Important as IHD risks are SYNERGISTIC
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Risk Stratification
• Calculates ABSOLUTE risk of CVD event in 10 years
1) Age2) Sex3) Cholesterol4) BP5) Smoking
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What is “high risk”?
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What is “high risk”?
• A >20% risk stratification
• i.e. Why statin therapy commenced at 20% risk
• ?Possibility of commencing “medium” risk?
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Artherosclerotic Plaques
• From 3rd decade – athroma build up – Angina
• From 4th decade – athroma plaque pathology – ACS
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Triad of IHD
Symptoms
ECG Changes Cardiac Markers
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Symptoms
• Again spectrum of symptoms – dependent on ischaemic pathology and severity
Exertional Angina STEMI
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ECG Ischaemic Changes
• Can IHD be investigated by performing a 12-lead ECG in a GP practice?
• Is a normal ECG at rest diagnostic of a non-ischaemic pathology?
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ECG Ischaemia
• 12-Lead ECG *During* acute event
Inducible Ischaemia1) Exercise ECG2) Stress ECG/Echo3) Myocardial Perfusion Scanning
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Cardiac Markers
• Should a GP request cardiac markers?
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Cardiac Markers - Spectrum
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Chest Pain Clinic
• Rapid Access Chest Pain Clinic• Part of “National Service Framework”
• Nurse Led• Risk Stratification• Perform Inducible Ischaemic Testing
• At end of clinic appt – cardiac cause ruled out• OR begin path of treatment and revasculariation
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Coronary Angiography
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Coronary Angiography
• Elective, Semi-Elective or Emergency
• Excellent as Diagnostic AND Therapeutic
• Whats involved?
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Coronary Angiography – for the GP
• “I had an angiogram and a stent last week and now I just feel awful......”
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Coronary Angiography – for the GP
• “I had an angiogram and a stent last week and now I just feel awful......”
• “I’m not eating and drinking, and I’m not passing much urine.......”
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Coronary Angiography – for the GP
• Renal Failure – incidence aprox 10%
• High risk group
• Contrast Load & dehydration
• Check the U&Es if asked to on the TTO!
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Coronary Angiography – for the GP
• “I had an angiogram last week and now I’ve got this bruise in my groin......”
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• Haematoma OR Pseudoaneurysm
• Difficult to diagnose clinically
• Refer for Cardiology Tertiary Centre
• Urgent Ultrasound diagnostic
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If the risk stratification and modification wasn’t enough.....
Acute Coronary Syndromes
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ACS - Spectrum
NSTEMI STEMI
• Diagnosed on Triad.....
• Managed the same?
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• NSTEMI – ACS protocol and semi-urgent angio +/- re-vascularisation
• STEMI – Immediate angio +/- re-vascularisation
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Revascularisation
• Angioplasty
• Stent Insertion
• CABG
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Post Discharge of ACS
Medications1) Aspirin 75mg OD2) Clopidogrel 75mg OD
3) Atorvastatin 40/80mg ON4) Ramipril – titrated to max dose5) Bisoprolol – titrated to max dose
6) PPI cover – Ranitidine vs. Lansoprazole
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Ideal Medications
1) Aspirin 75mg OD2) Clopidogrel 75mg OD
3) Atorvastatin 80mg ON4) Ramipiril 10mg ON5) Bisoprolol 10mg OD
6) Lansoprazole 30mg OD
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The Echo
• Guidelines state all patients should have an echo post ACS
• Reality?
• Important to assess LV function post-infarct• Guides:1) Management2) DVLA guidelines
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DVLA guidelines
• If untreated ACS (i.e. No stent)• 4 weeks
• If treated ACS (i.e. Stented)• 1 week
• No driving for 28 days if LVEF <40%
• 6 weeks for all HGV!
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Cardiac Rehab
• 8-12 week programme
• Statistically significant at reducing risk factors at 1 year follow-up
• 20% dec in re-infarction at 1 year
• GP refers if attended Tertiary Cardiology Centre
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STEMIs..... Which territory? Which vessel?
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ACS on ECGs is EASY
Inferior Anterior Lateral
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Territory - Vessel
• Inferior = Right Coronary Artery
• Anterior = Left Anterior Descending
• Lateral = Left Circumflex
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Which territory? Which Vessel?
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Which territory? Which Vessel?
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Which territory? Which vessel?
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STEMIs Overview
• Inferior – arrhythmias acutely - well long term
• Anterior – LV failure acute and long term
• Lateral – generally do well