Transcript CHS GP Teaching Afternoon 24Sept2014
GP Teaching Afternoon
Dr Asif Qasim 24 th September 2014
GP Teaching afternoon 1400-1500 – Dr Asif Qasim – Update • Real world cases • Common situations with interface between hospital, GP and community care • Questions and discussion 1500-1545 – Workshop 1 – Heart Failure / Heart Rhythm 1545-1600 – Coffee Break 1600-1645 – Workshop 2 – Heart Rhythm / Heart Failure
Case 1: 57 years, female
• Presented to A+E with 90 minutes ischaemic chest pain at 8am • No relevant PMH or regular medications • Smoker 15-20 cigarettes per day • ECG – lateral ST depression • Treated as Acute Coronary Syndrome • Admitted directly to CCU
Case 1: 57 years, female
Coronary angiography later that day Right radial approach Severe lesion in the first obtuse marginal Treated with PCI and stent implantation Plan for discharge
Case 1: 57 years, female
What treatments reduce her risk of future events?
1.
Antiplatelet therapy?
2.
Statin?
3.
ACE inhibitor?
4.
Beta blocker?
5.
Cardiac rehabilitation?
Case 1: 57 years, female
Cardiac Rehabilitation 1.
Smoking cessation 2.
Diet – increase in F+V, weight reduction 3.
Alcohol moderation 4.
Exercise – tailored program 5.
Proven reduction in morbidity and mortality
Case 1: 57 years, female
Secondary prevention medications: 1.
Statin 2.
ACE Inhibitor 3.
Beta-blocker?
Case 1: 57 years, female
Anti-platelet therapy 1.
Clopidogrel 2.
Prasugrel 3.
Ticagrelor
Case 1: 57 years, female
Questions?
Case 2: 65M
• HTN, Ex-smoker – seen in RACPC • 3/52Hx Central chest heaviness on walking up hill • DHx Amlodipine 5mg OD • Resting ECG TWF inferiorly • CXR normal • Exercise ECG: chest pain and ST depression in stage 2 Bruce • Treated with Aspirin, Bisoprolol, Simvastatin • Booked for coronary angiography
Angiogram
PCI and Stent to RCA
Nurse led PCI clinic and cardiac rehab • There is evidence that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors • Increased physical activity and combined dietary changes reduce mortality in coronary heart disease • Taylor RS et al (2004). Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med;116:682-92
Case 2:65M
• Did this patient get good care?
• Correct investigation?
• Appropriate treatment?
CG95 NICE CP of recent onset • Recent onset chest pain • ACS – urgent hospital assessment • Exclude non cardiac chest pain •
Investigation for stable angina
•
Pre-test probability of CAD
• •
No use of exercise ECG stress echo, CTA, MPI, Angiography
Risk stratification
CUH RACPC
- Less invasive angiography -Greater differentiation between at-risk groups -More CT/ DSE -More interaction between primary and secondary care
CTA Stress echo
OMT vs revascularisation
•
Courage study, NEJM (2007)
• 2287patients over 5 years • >70% stenosis in 1+ epicardial coronary artery and evidence of myocardial ischemia or at least one coronary stenosis of at least 80% and classic angina without provocative testing.
• Randomly assigned to PCI or optimal medical therapy • Success after PCI defined as angiographic success plus the absence of in hospital myocardial infarction, emergency CABG, or death.
• Primary outcome - death from any cause and nonfatal myocardial infarction. • Secondary outcomes - composite of death, MI / CVA and hospitalization for unstable angina with negative biomarkers
…but in COURAGE • • • • All patients had coronary angiography Half the patients had no evidence of ischaemia Less than 10% of screened patients were randomised Patients with critical lesions or strongly positive stress tests were excluded So the real conclusion from COURAGE: • Patients with chest pain who
might
lesions with
possible
have angina and have moderate coronary ischaemia have the same outcome with PCI as medical therapy
OMT • Aspirin and statin • First line beta-blocker or Ca antagonist • Add other agent or nitrate, nicorandil • Emerging evidence for Ronalazine • OMT – at least two anti-anginal agents
Prognostic CAD – should be revascularised • • • Obstructive LMCA lesion Proximal three vessel disease Proximal severe LAD lesion • Threatened occlusion • >10% ischaemia burden on stress echo • Consider use of pressure wire and FFR – FAME 1 and 2
CABG or PCI – MDM discussion •
Offer CABG for
• Prognostic disease • symptoms despite OMT and PCI is not appropriate.
•
Offer PCI for
• prognostic disease • symptoms despite OMT and PCI is appropriate.
•
Consider survival advantage of CABG over PCI for patients who are symptomatic despite OMT with
• Diabetes with MVD • • LMCA disease Complex multi-vessel disease
Questions
Case 3: 68 year old female
Atrial fibrillation – rate 110 Echo shows good LV and trivial MR. Dilated left atrium No exertional symptoms Aspirin only - No other regular medications Previous TIA with speech disturbance 12 months previously Normal CT, ECG and echo at that time
Case 3: 68 year old female
Rate or rhythm control?
Thrombo-embolic risk reduction?
Other tests?
Case 3: 68 year old female
New oral anticoagulant drugs: Dabigatran Rivoroxaban Apixaban
Case 3: 68 year old female
Case 4: 82 year old male
Admitted in June due to increasing SOB over 6 days and palpitations Known IHD, CABG 15 years ago known LV systolic dysfunction EF=30% Permanent AF O/E AF110 JVP to the ears, crackles to mid-zone moderate ankle oedema ECG AF rate 90-110 Baseline creatinine 150, hsTnT 45 CXR CCF, ULD, small right effusion
• On admission medications • Aspirin75mg • • Simvastatin 40mg Furosemide 80 mg od • • • • Spironolactone 25mg Could not tolerate b blockers Off ACE – hypotension Digoxin 125mcg • Treated with iv Furosemide 80 mg bd, • good response, lost 6 kg within a week, • however creatinine increased • Bisoprolol re introduced 1.25 and then 2.5 mg on 18/6
Planning for discharge
• • • • • • • Prolonged inpatient stay with iv diuretics for 26 days Seen by HF Specialist Nurses EF 30% on echo LBBB on ECG Consideration for CRT-D Advanced planning for end of life care Early FU with HF Specialist Nurses
How could we do better?
• Improving self care?
• Better community care?
• Health technology?
Self Care • • • Patient education and support Understanding Heart Failure Fluid balance • • • • • Patient self management Fluid intake and Urine output Daily weights Home heart rate and BP Diuretic dose adjustment • • • • Identifying exacerbations Red flags and worrying trends Seeking help early HF SN and early clinic access • • Better advanced planning Discussions about end of life
Community Care
• All CHS HF admissions to be seen by HF team • Early HF SN community FU for all HF discharges • • • • Community iv diuretics Avoid admission Early discharge on iv diuretics CHS uniquely placed – national challenge in HF • Better advanced planning
Health Technology
• Telephone clinics • • • • • • Telemetry at home Pulse ECG BP Respiratory rate Weight • • • • Device therapy – CRT Improved technology Broader indications Better advanced planning and end of life care
Single-Lead ECG Heart Rate Heart Rate Variability Respiratory Rate Skin Temperature Body Posture including Fall Detection Steps Stress Sleep Staging (Hypnogram) • Cloud connectivity • Close home monitoring • Smart algorithms • Home hospital….
Available in the coffee break