Transcript Cardiovasculat presentation from Kay Elliotx

Ian Davies
Ian Davies
Mr Davies is a 57 year old –self-employed IT
consultant
Discharge summary:
• STEMI – PPCI- 2 x DES
• Past medical history: nil of note
• Medication: aspirin 75mg, clopidogrel 75mg, bisoprolol
2.5mg, ramipril 2.5mg, atorvastatin 80mg & GTN spray
Ian Davies
First GP review one week post discharge
• He continues to smoke (although he’s cut down a bit) and he has a
strong family history of coronary heart disease ; offered smoking
cessation support
• Reports occasional left chest discomfort always at rest eases if he
changes position
• Blood Pressure: 145/90mmhg & Heart Rate: 50 bpm, regular
• Diet high in sat fats – BMI 34; – hasn’t engaged with cardiac rehab
Ian Davies
First GP review one week post discharge
http://lifeinthefastlane.com/ecg-library/anterior-stemi/
What event and interventions has
Mr Davies experienced?
STEMI – PPCI- 2 x DES
• ST elevation myocardial infarction treated with
• Primary percutaneous coronary intervention and
• 2 x Drug eluting stents
What’s missing?
Discharge summary:
• STEMI – PPCI- 2 x DES
• Past medical history: nil of note
• Medication: aspirin 75mg, clopidogrel 75mg, bisoprolol
2.5mg, ramipril 2.5mg, atorvastatin 80mg & GTN spray
Medication changes needed?
Discharge medication GP Review
aspirin 75mg
clopidogrel 75mg
bisoprolol 2.5mg
ramipril 2.5mg
atorvastatin 80mg
GTN spray
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Is Mr Davies taking them?
How/when is he taking them?
Side-effects/problems
Uptitrate/monitor (ramipril/bisoprolol)
How to use GTN
When to stop clopidogrel
Eplerenone?
“For patients who have had an acute MI and who have
symptoms and/or signs of heart failure and left ventricular
systolic dysfunction, initiate treatment with an aldosterone
antagonist licensed for post-MI treatment within 3–14 days
of the MI, preferably after ACE inhibitor therapy”
(NICE, CG172)
Secondary Prevention & Statins
Atorvastatin 80mg – do not delay
• This should be continued unless the patient cannot
tolerate, has abnormal LFT’s, or patient preference (AST,
ALT, GGT: do not exclude if transaminases less than 3 times the upper limit)
• Target <40 % reduction in Non HDL
• Check LFT at 3 months, then at 12 months (annual review?)
• If unexplained muscle symptoms consider stopping statin
immediately – (Check CK: x 5 upper limit of normal or more - stop statin)
Follow-up
Check patients’ understanding of their:
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Diagnosis and risk of re-stenosis
secondary prevention measures required
medication regime
cardiac rehabilitation
what do they think are the key problems; work, travel,
finance, getting back to hobbies/driving…..?
Plan for:
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drug titration
length of dual anti-platelet therapy
follow-up blood tests/physical examination
Check follow-up with cardiologist is in place
John Bryant
John Bryant
Mr Bryant is 64 years old and had a primary prevention
CRT-D fitted in 2010 for severe LV systolic dysfunction
and he also is known to have ischaemic heart disease.
He felt much better in terms of his heart failure symptoms after
implant initially
Over the last three weeks his heart failure symptoms have
returned;
He has gained 5 lbs in weight, he is breathless
on minimal exertion and his ankles are swollen.
John Bryant
What action might you take?
John Bryant
• ask about other symptoms; angina, palpitations,
syncope/pre-syncope, orthopnoea, paroxysmal nocturnal
dyspnoea
• physical examination
• blood Tests: U&E, ?FBC,
• consider ECG depending on examination and symptoms
• treat heart failure symptoms
• Is medication optimised? Check medication concordance
and for any significant lifestyle change
Evidence Based Medicine for
LVSD
Optimal titration of appropriate
• ACE Inhibitors (CONSENSUS, SOLVD, SAVE, AIRE,TRACE)
• βblockers (CIBIS II, COPERNICUS, MERIT-HF, SENIORS)
• MRAs (RALES, EMPHASIS-HF)
reduces mortality at 12 months from 44% to 17%
National Heart Failure Audit, 2015
John Bryant
• Contact ICD centre for sooner ICD check:
– is LV lead working?
– Does he need biventricular optimisation?
• Is referral to or advice from cardiologist indicated?
John Bryant
Calculate stroke risk score with:
• Symptomatic, asymptomatic, paroxysmal, persistent
or permanent atrial fibrillation
• Atrial Flutter
• a continuing risk of arrhythmia recurrence after
cardioversion back to sinus rhythm
Do not offer Aspirin monotherapy solely for stroke
prevention to people with atrial fibrillation
*National Clinical Guideline Centre (NCGC) 2014
**The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC - 2012)
Stroke risk
CHA2DS2-VASc Score
C
H
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V
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Sc
Congestive heart failure?
Hypertension
Age >75 yrs
Diabetes
Stroke ,TIA or thromboembolism
Vascular disease
Age 65-74
Sex category (female)
1
1
2
1
2
1
1
1
Points
(max 9)
Ensure that anticoagulation is discussed and offered to individuals with a score of
≥2, and considered for all those with a score of 1, except if they are aged <65 yrs
and the point is due to female gender alone
(NICE, CG180)
Bleeding Risk: HAS-BLED
H
A
S
B
L
E
D
Hypertension
Abnormal renal and liver function*
Stroke
Bleeding
Labile INRs
Elderly >65years
Drugs eg aspirin, NSAID, alcohol*
1
1 or 2
1
1
1
1
1 or 2
*1 point each.
A Score >=3 indicates high risk
Therefore, caution required with either anti-platelet or oral anticoagulant
therapy
Atrial Fibrillation
ESC Guidelines 2012
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Most common arrhythmia in HF
Increases stroke risk
May lead to worsening of symptoms
Identify correctable causes
Identify potential precipitating factors
Determine rhythm or rate control strategy
Assess for thromboembolism prophylaxis
In LVSD BB preferred to digoxin for rate control
IN HF-PEF rate limiting CCBs are an alternative
Typical course of heart failure
http://www.nhsiq.nhs.uk/media/2574509/end-of-life-care-in-heart-failure-framework-for-implementation.pdf
Mike Baker
Mike Baker
Mr Baker is 46 years old, married with two
daughters (five and three years old)
PMH: Born with a malformed aortic valve
Developed flu like symptoms, which would
not resolve
Mike Baker
• Reviewed by GP’s (x3) over five months
• Diagnosed with flu
• Treated with steroids, NSAID’s and sent
for chest x-ray
Mike Baker
He continued to worsen over five months:
• One stone weight loss
• Severe cough
• Breathless on stairs
Mike Baker
His wife finally took him to hospital:
• Diagnosed with endocarditis (aortic valve)
• IV antibiotics (via PICC Line)
• Developed atrial fibrillation
• Cardiac arrest and failed resuscitation
Mrs Claire Baker
Following the death of her husband Mrs
Baker would like to know that:
• Those at risk know what to look out for
• Healthcare practitioners remember to
consider/investigate possible endocarditis
At risk of infective endocarditis:
• acquired valvular heart disease with stenosis or
regurgitation
• hypertrophic cardiomyopathy
• previous infective endocarditis
• structural congenital heart disease, including surgically
corrected or palliated structural conditions (but excluding isolated
atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus
arteriosus, and closure devices that are judged to be endothelialised)
• valve replacement
NICE, CG64
Advise ‘at risk’ patients
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Good oral hygiene & regular dental review
Avoid body piercing and tattooing
Don’t inject non-prescription drugs
Any infection; report it to your GP immediately
carry an Endocarditis warning card; show to any
other health professionals who may need to give
you treatment
CVD Clinical Development Coordinator
Can provide in-house education for your team:
[email protected]
• Often interactive
with questions
and case studies
throughout
Presentations
• Facilitated
discussions &
reflection
• Case studies
Group Work
• Individual practice
(ECG reading) –
worksheets,
practice ECG’s
• Quizzes
Individual
work or in
pairs
How to order BHF
Resources
All our resources are free to order, although we do ask for
a donation if you can afford one.
Web:
bhf.org.uk/publications
Call:
0870 600 6566
Email:
[email protected]
References
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European society of cardiology ( 2012) Guidelines for the diagnosis & treatment
of acute and chronic heart failure. The task force for the diagnosis and treatment
of chronic heart failure of the European society of cardiology, European Heart
Journal
National Institute for Clinical Excellence
Acute Heart Failure (CG187) October, 2014
Atrial Fibrillation (CG180) June 2014
Chest pain of recent onset (CG 95) March 2010
Chronic Heart Failure (CG 108) August 2010
Management of stable angina (CG 126) July 2011
Unstable angina and NSTEMI (CG 94) March 2010
MI with ST segment elevation (CG 167) July 2013
MI – secondary prevention (CG172) November 2013
NICE quality standard (QS99) September 2015
Prophylaxis against infective endocarditis overview (CG64) Sept, 2015
• http://www.nhsiq.nhs.uk/media/2574509/end-of-life-care-in-heart-failureframework-for-implementation.pdf
• National Heart Failure Audit (2015) https://www.ucl.ac.uk/nicor/audits/heartfailure
• British heart Foundation (www.bhf.org.uk)