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
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Presented to A+E with 90 minutes ischaemic chest pain at 8am
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No relevant PMH or regular medications
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Smoker 15-20 cigarettes per day
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ECG – lateral ST depression
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Treated as Acute Coronary Syndrome
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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
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HTN, Ex-smoker – seen in RACPC
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3/52Hx Central chest heaviness on walking up hill
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DHx Amlodipine 5mg OD
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Resting ECG TWF inferiorly
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CXR normal
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Exercise ECG: chest pain and ST depression in stage 2 Bruce
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Treated with Aspirin, Bisoprolol, Simvastatin
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Booked for coronary angiography
Angiogram
PCI and Stent to RCA
Nurse led PCI clinic and cardiac rehab
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There is evidence that exercise based cardiac rehabilitation reduces all
cause and cardiac mortality and improves a number of cardiac risk factors
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Increased physical activity and combined dietary changes reduce mortality
in coronary heart disease
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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
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Recent onset chest pain
• ACS – urgent hospital assessment
• Exclude non cardiac chest pain
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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
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Courage study, NEJM (2007)
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2287patients over 5 years
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>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.
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Randomly assigned to PCI or optimal medical therapy
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Success after PCI defined as angiographic success plus the absence of inhospital myocardial infarction, emergency CABG, or death.
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Primary outcome - death from any cause and nonfatal myocardial infarction.
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Secondary outcomes - composite of death, MI / CVA and hospitalization for
unstable angina with negative biomarkers
…but in COURAGE
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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:
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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
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Aspirin and statin
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First line beta-blocker or Ca antagonist
• Add other agent or nitrate, nicorandil
• Emerging evidence for Ronalazine
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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,
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crackles to mid-zone
moderate ankle oedema
 ECG AF rate 90-110
 Baseline creatinine 150, hsTnT 45
 CXR CCF, ULD, small right effusion
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On
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admission medications
Aspirin75mg
Simvastatin 40mg
Furosemide 80 mg od
Spironolactone 25mg
Could not tolerate b blockers
Off ACE – hypotension
Digoxin 125mcg
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Treated with iv Furosemide 80 mg bd,
• good response, lost 6 kg within a week,
• however creatinine increased
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Bisoprolol re introduced 1.25 and then 2.5 mg on 18/6
Planning for discharge
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Prolonged inpatient stay with iv diuretics for 26 days
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Seen by HF Specialist Nurses
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EF 30% on echo
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LBBB on ECG
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Consideration for CRT-D
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Advanced planning for end of life care
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Early FU with HF Specialist Nurses
How could we do better?
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Improving self care?
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Better community care?
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Health technology?
Self Care
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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
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All CHS HF admissions to be seen by HF team
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Early HF SN community FU for all HF discharges
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Community iv diuretics
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Avoid admission
Early discharge on iv diuretics
CHS uniquely placed – national challenge in HF
Better advanced planning
Health Technology
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Telephone clinics
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Telemetry at home
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Device therapy – CRT
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Pulse
ECG
BP
Respiratory rate
Weight
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….
Asif.Qasim@croydonhealth.nhs.uk
Ejatu.Renner@croydonhealth.nhs.uk
Available in the coffee break