Clinical Update / Cardiac
Rehabilitation
Maureen Geens SRN BSc (Hons)
Sponsored by BHF
Objectives
Brief clinical update
Cardiac Rehabilitation
Case Studies
Incidence rate (per 100,000)
Trends in Acute Coronary Syndrome (ACS)
180
1975–1978
1990–1991
160
1981–1984
1993–1995
140
1986–1988
1997
120
100
80
60
40
20
0
Q-wave
Non Q-wave
Reprinted with permission: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80
Classification of ACS
ACS
ECG
ST Elevation
Aborted MI
No ST Elevation
Troponin
.
STE/ACS
Myonecrosis
confirmed
STEMI
NSTEMI
TnT > 50
Myonecrosis
not confirmed
TnT+ve -ve
ACS
UA
15-49 < 15
NSTEMI
Initial diagnosis Troponin T/I increase and clinical picture.
Management – oral antiplatelets
Percutaneous coronary intervention (PCI) 2-3 days later unless
symptoms continue
Discharge 12-24 hours post PCI
Medication: aspirin, clopidogrel/prasugrel, beta-blocker, +/- ACE
(angiotensin converting enzyme inhibitor), statin
If PCI successful may drive after 1 week otherwise
4 weeks (DVLA 2008)
Cardiac Troponin (cTn) I and T
Best marker of myocardial injury
Normal levels very low
In patients with symptoms compatible with an acute coronary
syndrome:
- Increased cTN I or cTn T indicates 4-fold increased risk of
death/MI
- Indicates high-risk group who benefit from aggressive
management:
Use of enoxaparin/Use of GP IIb/IIIa inhibitor
Early invasive strategy
STEMI
Diagnosis ECG, clinical picture
Primary percutaneous coronary angiography
(PPCI)
Medication - aspirin, clopidogrel/prasugrel,
ACE (angiotensin converting enzyme)
inhibitor, beta-blocker, statin
May drive after 1 week
PLAQUE RUPTURE AND THROMBUS FORMATION
ADP
Red blood
cell
Platelets
Fibrin
strands
Fibrous
cap
Smooth
muscle
cells
FRESH ATHEROTHROMBOSIS
Vessel wall
Thrombus
Atheromatous
plaque
Red cellrich regions
Fibrin-rich
regions
Vessel lumen
Acute Coronary Syndromes
Suppression of intimal proliferation
Bare metal stent versus Drug Eluting Stent
BMS
DES
… DES are highly effective
Primary PCI pre / post
Drug Therapy
All patients who have had an acute MI should be
offered treatment with the following drugs
ACE (angiotensin-converting enzyme) inhibitor
Aspirin, Clopidogrel/Prasugrel
Beta-blocker
Statin
Why Cardiac Rehabilitation
What can we do?
Definition of Cardiac
Rehabilitation
“ the sum of activities required to influence
favourably the underlying cause of the
disease, as well as the best possible,
physical, mental and social conditions, so
that people may, by their own efforts
preserve or resume when lost, as normal a
place as possible in the community.
Definition of Cardiac
Rehabilitation
“Rehabilitation cannot be regarded as an
isolated form or stage of therapy but must
be integrated within secondary prevention
services of which it forms only one facet”.
Geneva WHO 1993
National / Local guidelines
National Service Framework (CHD), (DOH
2000).
BACR (2007)
Strategic Commissioning Development Unit
(SCDU 2010)
Local Cardiac Service Review (2010/11)
Patients referred to our service
Patients post Acute myocardial infarction +/- PPCI
or PCI
Patients post CABG and Valve surgery
Patients following other cardiac surgery on
individual basis
Elective or emergency PCI patients
Patients with ICD
Patients with diagnosis of left ventricular systolic
dysfunction
Service offers an individualised
assessment to include:
History
Clinical assessment
Risk factor assessment
Lifestyle advice
Medication review and optimising therapy
Quality of life and Hospital and Anxiety
Depression (HAD) scoring
Service offers an Individualised
assessment to include
Social and vocational status
Exercise programme
An agreed individualised care management plan
Ongoing clinical assessment, monitoring and
support
Education facilitation of self management
Pro active monitoring and early intervention
Psychological support
Atrial Fibrillation and stroke
risk reduction
All patients receive a manual pulse check and have a
CHADs2 score completed.
Patients in AF will be risk assessed for stroke and
with the CHADs2 score will be discussed with the GP
The cardiac nursing team are involved in raising
awareness of manual pulse checking and have
delivered education sessions to support the ‘stroke
strategy’ and risk reduction in AF
Exercise programme
Provided by specialist cardiac
physiotherapist and support therapist
Individual assessment
Functional capacity and METs
Individualised programme
Method of delivery
Individualised Home based
One to one clinic based
Low /medium risk / supervision group setting
High risk / supervision group setting
Cardiac Service Delivery
Home visits
Cardiac nurse clinic
Telephone support
Telehealth monitoring
Heart Manual, angioplasty plan facilitation
Communication
Directly with GP if there is a clinical concern – telephone / email
Correspondence with letters / email – dependent on preferred
route
Attending MDTs
Liaising with practice nurses as necessary
Direct communication with consultants as necessary
Direct links in to acute trust & departments
Communication and liaising with all members of the
multidisciplinary team to optimise patient care and management
Audit
The service has a focussed, consistent approach
to audit and monitoring outcome measures for all
aspects of the service. This includes the input of
data into both local and national databases.
National Audit for Cardiac Rehabilitation (NACR)
Athena
Professional / clinical
support
The nurses attend clinical mentorship from a
cardiologist on a regular basis
Good access to GPWSI cardiology
Supported by the BHF – education etc
Service lead – county meetings, regular 1:1s
Peninsular forums for both CR & HF
Case Study 1
52 year old male - Smoker
Positive family history
HGV driver
STEMI – PPCI
Discharged
Cardiac rehabilitation referral
Unable to drive HGV until treadmill
approximately 4-6 months, implications financially
Case Study 2
65 year old male - Farmer
Ex-smoker stopped after MI 8 weeks ago
Positive F/H
Severe triple vessel disease Coronary Artery Bypass
Graft (CABG)
Discharged 7 days post operatively cardiac
rehabilitation referral
Drive within 6 weeks
Smoking Cessation
The cardiac effects of smoking are reversed within 2-3
years of stopping
Five years after stopping, a smokers CV risk is the same
as if they had never smoked
Level II/III smoking cessation services
Use of new drugs, such as varenicline (NICE TA123)
Consistent smoking cessation advice from HCPs
Any Questions?