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GP Teaching Afternoon Dr Asif Qasim
24th 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 have angina and have moderate coronary lesions with possible 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 ECGHeart RateHeart Rate VariabilityRespiratory RateSkin TemperatureBody Posture including Fall DetectionStepsStressSleep Staging (Hypnogram)
• Cloud connectivity
• Close home monitoring
• Smart algorithms
• Home hospital….
[email protected] Available in the coffee break
