Transcript Coronary Heart Disease Presentation Sept 13

Reducing the risk
of CHD
Jane Dudley
Heart Failure
Specialist Nurse
Cardiovascular Disease
– a Public Health Issue
 Diseases of the heart and circulatory system
are called cardiovascular diseases or CVD.
 CVD are the main cause of death in the UK
- approximately 198,000 deaths a year( BHF
2006)
 Main forms of CVD are coronary heart
disease (CHD) and stroke.
 Approximately 48% of all deaths from CVD
are from CHD; approximately 28% are from
stroke.
 CHD is the most common cause of death in
the UK – 1 in 5 men and 1 in 7 women die
from the disease.
 94,000 deaths in the UK are from CHD (
BHF 2006)
2
Health inequalities
 Death rates from CHD are highest in
Scotland and the North of England, lowest in
the South of England.(BHF 2006)
 Estimated that every year 5,000 lives and
47,000 working years are lost in men aged
20 to 64 years due to social class
inequalities in CHD death rates.
 In England and Wales evidence of strong
links between deaths from cardiovascular
disease and levels of deprivation.
 To reduce socio- economic inequalities CVD
inequalities targets have been introduced in
England, Scotland and Wales(BHF 2006)
 Latest evidence suggests that progress
towards the CVD indicators is steady but if it
continues the inequalities gap should be
reduced by 2010.
3
4
5
6
7
8
Cardiac Markers
 Cardiac markers are cardiac enzymes and
cell contents.
 The measurements of Troponin I and T are
of equal clinical values (SIGN 2007)
 Optimum time to measure troponin for
diagnosis or prognostic risk is 12 hours from
the onset of symptoms (SIGN 2007)
9
Cardiac Markers
Continued
 STEMI: Elevated cardiac markers, which
indicate necrosis in the heart muscle (plus
ST elevation on ECG)
 NSTEMI: Elevated cardiac markers which
indicate necrosis in the heart muscle (no ST
elevation on ECG).
 Unstable Angina: No elevated cardiac
markers, no necrosis of heart muscle (no ST
elevation on ECG)
10
11
ST Elevation
12
13
14
Definitions
 ACS: Acute Coronary Syndrome.
• Refers to a range of acute myocardial
ischaemic states. Encompasses
Unstable Angina, NSTEMI and STEMI
 Unstable Angina
• Ischaemia caused by obstruction of a
coronary artery due to plaque rupture
with thrombosis and spasm
15
Definitions continued
 NSTEMI: Non ST segment elevation
myocardial infarction
 STEMI: ST segment elevation myocardial
infarcton
 Unstable Angina and NSTEMI account for
approximately 2.5 million hospital
admissions worldwide
 25% of admissions of chest pain (not
necessarily cardiac in origin)
16
Coronary Heart Disease
 CHD kills 110,000 people
 1.4 million people suffer with angina
 275,000 suffer a heart attack Each year
17
Smoking Cessation
 70% of smokers under 65yrs want to stop.
 43% of smokers over 65yrs want to stop.
 Main drivers are health and financial.
 Awareness of the dangers of passive smoking
seemed to have an affect on motivation.
 Smokers who have support with cessation are
most likely to succeed.
 NRT doubles the chances of successful
cessation.
18
Physical Activity
 Physical activity reduces the risk of chd
 The physically inactive have twice the risk of
developing chd
 3% of all disease and 24% of chd can be
attributed to physical inactivity
 Aerobic activity provides most benefit
 30 mins of moderate exercise 5 times a week
is optimum
19
Hypertension
 Direct link between chd and BP.
 Each rise in BP by 20mmgh systolic and
10mmgh diastolic will double chd mortality
risk.
 11% of all disease, 50% of CHD and 22% of
heart attacks attributed to hypertension.
 Optimum: 120/80mmgh.
 Treatment should be commenced at BP over
140/90mmgh or 135/85mmgh in diabetics.
20
Alcohol
 High alcohol intake accounts for 9% of all
disease and 2% of chd
 Is beneficial in small quantities
 Women 2-3 units per day
 Men 2-4 units per day
 Binge drinking increases the risk of chd
21
Psychosocial Well
Being
 Work stress
 Lack of social support
 Anxiety and depression
 Personality traits such as hostility
22
Healthy Eating and
Obesity
 30% of CHD deaths are caused by an
unhealthy diet
 4% of disease and 30% of CHD is due to poor
consumption of fruit and vegetables
 Abdominal fat distribution is an indicator of
greatest CHD risk in the obese
 7% of disease, 1/3 of CHD, 60% of
hypertension and 63% of heart attacks are
caused by obesity
23
General Weight Loss
Advise
 Every kg of excess
weight contains
7500 Kcals, a
reduction of 1000
cals per day will lead
to 1kg weight loss
per week
Food diaries to
look at:
 Meal patterns
 Likes and dislikes
 Hard to resist foods
 Portion sizes
 Work and home
arrangements for
cooking and eating
24
 Portion sizes:
 3 tbls breakfast
cereal
 2 heaped tbls rice
 2 egg sized
potatoes
 Carbohydrates,
proteins, fruit and
vegetables all
create a feeling of
fullness.
 High fat and sugary
foods should be
avoided but an
occasional treat will
not jeopardise
months of dieting.
25
Eating for a Healthy
Heart
 5 portions of fruit and vegetables a day
 Reduce saturated fat and replace with poly or
mono unsaturated fats
 Oily fish once a week
 No more than 6 grams of salt a day
 High fibre to reduce absorption of dietary
cholesterol
26
What is cholesterol?
 Fatty substance
produced by the
liver
 Also found in some
foods
 Cholesterol is
released when
saturated fat is
digested
 Cholesterol is
carried around the
body by LDL, HDL
and triglicerides
 LDL cholesterol
contributes to the
development of
atheroma
 HDL cholesterol
transports
cholesterol out of
the body
 Optimum is to have
high HDL and low
LDL
27
Cholesterol and CHD
 Direct link between cholesterol and CHD
 Raised cholesterol accounts for 8% of all
disease and 60% of CHD
 45% of heart attacks are caused by raised
cholesterol
 Recommended level- 4-5 with a HDL
greater than 1
28
Reducing cholesterol
 Reduce saturated fat intake
 Statins (simvastatin) reduce cholesterol and
provide overall reduction in CHD risk
 All patients who have had a heart attack,
have angina or have a cholesterol greater
than 5 should be on a statin unless contra
indicated
29
SMOKING
 Ten million smokers in England
 20% of CHD deaths in men and 17% in
women are attributed to smoking
 Smoking cessation reduces risk of CHD by
50% in the first year, followed by a gradual
decline to that of a non smoker
 Smoking cessation following a heart attack
reduces the risk of further heart attack by 2429%
30
Diabetes
 Type 1 diabetics do not produce any insulin.
 Type II diabetics have a relative lack of insulin
due to resistance.
 Men with type II diabetes have 2-4 fold risk of
developing chd and women a 3-5 fold risk
compared to non diabetics.
 Diabetes increases the risk of heart attack by
3 fold.
 Type II diabetes magnifies other risk factors
and those with type II diabetes are more likely
to have other risk factors.
 15% of heart attacks are caused by diabetes.
31
Conclusion
CHD is:
 Hereditary
 More likely to develop with increasing age
 Is more prevalent in the male population
HOWEVER
For a large proportion of people it is
PREVENTABLE
 Simple changes can have significant results
 Health care assistants can assist with the
governments drive to reduce CHD in the
UK
32
References
 Department of Health (2000)
National Service Framework for Coronary Heart
Disease
 Hinchliffe S, Montague S, Watson R (2000)
Physiology for Nursing Practice
 www.bhf.org.uk
 www.heartstats.org
33
Heart Failure - a
definition
Heart failure is a complex syndrome that
can result from any structural or functional
cardiac disorder that impairs the ability of
the heart to function as a pump to support
a physiological circulation. (NICE 2010)
34
Echocardiogram
 An echocardiogram is a non invasive
investigation to look at the atria and
ventricles in the heart and assesses for any
pathological changes that may be affecting
the function of the heart. It also provides an
ejection fraction figure which refers to the
percentage of blood pumped out from the
left ventricle. The procedure can be done as
an outpatient or through the Community
Echocardiogram service.
35
 ■ It
is estimated that over 5% of all deaths in
the UK are due to heart failure.
 ■ People with heart failure have a lower
quality of life than people with arthritis,
chronic lung disease or angina.
 ■ In England 2% of all inpatient bed days are
due to heart failure. This is projected to
increase by 50% over the next 25 years.
 ■ Annual cost of heart failure to the National
 Health Service in the UK is about £625
million
36
The Health Service cost
of Heart Failure
Outpatient
investigations
6%
OPD care
8%
Drugs
9%
Primary Care
17%
Inpatient care
60%
37
Aims
 Bridge the gap between primary and
secondary care
 Patient and carer focused
 To optimise the management and improve
the quality of life experienced
 Prevent unnecessary hospitalisations
 Patient journey as smooth as possible and not
fragmented
 Proactive intervention rather than reactive
response.
38
Aims of the Community
Heart Failure Nurse
 To offer interventions appropriate to the
patients needs, incorporating psychosocial
and educational input and a review of their
medical condition/treatment.
39
Causes of Heart Failure







Coronary heart disease/ischaemia
Hypertension
Heart valve disease
Arrhythmias
Thyroid Dysfunction
Chronic Anaemia
Cardiomyopathy – alcoholic, drug
induced,congential, ichaemia.
40
New York Heart Association
Classification
 NYHA class 1 – Symptoms do not occur
during normal activity
 NYHA class 2 – Symptoms slightly limit
normal activity
 NYHA class 3 – Marked limitation of
normal activities without symptoms at
rest
 NYHA class 4 – Unable to undertake any
physical activity without symptoms.
Symptoms at Rest.
41
 Most sensitive symptom of heart failure
 Pulmonary oedema (fluid on the lungs) –
back pressure on the lungs from an
overloaded left atrium.
 Overdrive of the breathing muscles
 Weakness of breathing muscles
42
Signs and Symptoms of
Heart Failure




Fatigue/tiredness
Breathlessness
Peripheral oedema
Disturbed sleep( nocturnal cough;
breathlessness)
 Difficult in concentrating ( hypoxia;
lethargy)
 Depression (anxiety; poor prognosis)
 Impaired appetite
43
Assessment of fluid
status
 Daily weights
○ 1kg weight gain = 1 litre fluid
 Look for oedema (usually evident when 5
litres of fluid is retained)
○ Feet / ankles
○ Calves
○ Thighs
○ Abdominal ascites
○ Sacral
○ Pitting?
44
Fluid Retention /
Oedema
 Heart failure causes back pressure on the
circulation.
 Increased venous pressure causes fluid
build up in other tissues e.g. lungs,
peripheries, abdomen.
 Reduced cardiac output leads to reduced
blood flow to kidneys which results in sodium
and water retention.
45
Leg Oedema
46
47
Tiredness / Fatigue
 Fatigue is almost always present in heart
failure.
 Skeletal muscle changes
 Effortful breathing
 Poor sleep quality
 Reduced oxygen in the blood
 Reduced ability to respond to exertion
48
Assessment of
tiredness / fatigue




Changes in exercise / activity tolerance
Activities of daily living
Muscle weakness
Pain
49
Day to day management
 Review of daily weights – action if weight
has increased over the last 3 days by 2-4
kgs (4-8lbs).
 Fluid restriction if necessary (1.5-2litres)
 Symptom review
 Blood pressure (sitting and standing)
 Heart rate and regularity
50
Day to day management






Medication Review
Optimisation of medication
Education and support
Self management
End of life choices and care
Lifestyle advice – diet, exercise, smoking,
etc
51
Other therapy
 Coronary Revascularisation
 Valve Replacement
 Implantable defibrillators
 Biventricular pacing
 Left Ventricular Assist Devices (LVAD)
 Cardiac Transplantation
 Gene and cell therapy
52