Katherine Rothwell Case 1 65 yr old female PMHx Eczema is a smoker 20day Comes to see you complaining of central chest pain Present past few months Comes on when gardening or when outside in the cold ID: 1035978
Download Presentation The PPT/PDF document "Ischaemic Heart Disease" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Ischaemic Heart Disease Katherine Rothwell
2. Case 165 yr old femalePMHx : Eczema, is a smoker 20/dayComes to see you complaining of central chest painPresent past few months.Comes on when gardening or when outside in the coldSettles if restsNot SOB and no radiationO/E – HR 75 regular, Sats 96% BP 150/88, HS normal, Chest- clearWhat is the diagnosis? What would you do?
3. AnginaAffects 2% of the population of the UK.Incidence increases with ageMale > female CAUSESMostly atheroma of the coronary arteriesAnaemiaAortic stenosisTachyarrhythmiasHOCMArteritis/small vessel diseaseThyrotoxicosis
4. Angina: DiagnosisTypical symptomsConstricting discomfort in front of the chest, neck shoulders, jaw or armsTriggered by physical exertionRelieved by rest or GTN within 5 minsTypical angina- all 3 featuresAtypical angina – 2 featuresNon-anginal chest pain – one or none of the featuresOther risk factors : inc age, male sex, smoking, diabetes, HTN, dyslipidaemia, FHx of premature CAD, h/o established CAD
5. IHD InvestigationsResting ECGBloods – Lipids, FBC, Hba1c, U+E, LFTs, TFTsCVD risk Usually refer to cardiology- RACPCan provide GTN spray and consider AspirinSafety net for any symptoms of MI/ACS
6. IHD : Management in primary careLifestyle: exercise, diet, smoking, driving and occupation Medication : GTNBetablocker or Calcium- channel blockers – to reduce symptoms of stable anginaIf both CI or not tolerated, long acting nitrate (ISMN), Nicorandil, IvabridineReview response 2-4 weeks after startingSecondary preventionConsider Aspirin 75mg od Statin ACEI
7. Case 280yr old malePMHx : Angina, HTN, DMSeen as emergency in morning surgery at 11am. Reports episode of chest pain whilst watching football at 8pm last nightFelt like angina pain, but came on at rest and didn’t go with GTN. Lasted 30 minutes then settledNo further pain sinceO/E – BP 126/78 HR- 80 sats 96%. HS normal, Chest- clearWhat is the diagnosis? What would you do?
8. Acute Coronary Syndrome/Myocardial InfarctionHistoryPain in chest (or arms, back or jaw) lasting longer than 15mAssoc with nausea and vomiting, sweating or breathlessness or combination of theseAssoc with haemodynamic instability (e.g. systolic <90)New onset pain, or abrupt deterioration of stable angina, with pain occurring frequently with little or no exertion and often lasting longer then 15m
9. Suspected ACS/MI assessment Most people require referral or admission to hospital to confirm the diagnosis of ACS/MIAn ECG and blood test for highly sensitive troponin to confirm diagnosisIn GP land :Examine the patientDo an ECG
10. Suspected ACS/MI :ManagementAdmission (Consider ambulance):Abnormal clinical features – rr>30, hr 130, low BP, low 02 sats, high tempIf current chest painComplications – pulmonary oedemaAre pain free, but pain within 12hrs and abnormal ECG or if ECG not availableOffer GTN and Aspirin if in pain
11. Suspected ACS/MI Management not requiring ambulanceRefer for same day assessment if :Chest pain in last 12hrs and normal ECG and no complicationsChest pain 12-72 hrs and no complicationsWithin 2 weeks ref:Suspected ACS,now pain free, chest pain more than 72 hrs and no complications Use clinical judgement, interpretation of the 12-lead resting ECG, and high-sensitivity blood troponin measurement to decide how urgent this referral should beconsider discussing prior management with a cardiologist
12. Myocardial Infarction: Management in Primary CareLifestyle advice :alcohol, cardioprotective diet, exercise, loosing wt, stopping smokingCardiac rehabMedications:Aspirin/Clopidogrel (both for 12m after NSTEMI, just 4 weeks after STEMI – depends on stent)ACEI Beta blockersStatins (reduce cholesterol to 5 or LDL <3 or 30% reduction)
13. Primary Prevention of IHDEstimate CVD risk FraminghamJBSQRISK – www.qrisk.orgLooks at multiple factors to determine 10 year risk of having MI/CVA
14.
15. Lowering CVD risk : lifestyle changesLoosing weight to get BMI 25Reduce fat intake5 portions fruit and veg a dayLimit alcohol intake to <14units a weekReduce salt intake <6g/dayRegular exercise – 30 minutes + aerobic activity most daysSmoking cessation
16. Lowering CVD risk : Treatment optionsStatins – if CVD risk 10% (atorvastatin 20mg)Treatment of hypertension – according to NICE