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Ischaemic Heart Disease for the GP

Ischaemic Heart Disease for the GP. Chris Tracey GPVTS. What is Ischaemic Heart Disease?. Artherosclerotic build-up Preventing perfusion to myocardium Spectrum. Ischaemic Spectrum. Epidemiology. Cardiovascular disease deaths 240,000 (2004) IHD deaths 117,000 (2004) Mortality decreasing

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Ischaemic Heart Disease for the GP

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  1. Ischaemic Heart Disease for the GP Chris Tracey GPVTS

  2. What is Ischaemic Heart Disease? • Artherosclerotic build-up • Preventing perfusion to myocardium • Spectrum....

  3. Ischaemic Spectrum

  4. Epidemiology • Cardiovascular disease deaths 240,000 (2004) • IHD deaths 117,000 (2004) • Mortality decreasing • Incidence stable • Cost £1.7 billion in healthcare alone

  5. Risk Factors • Split into Modifiable and Non-Modifiable

  6. Non-Modifiable • Increasing age • Male Gender • Family Hx • Ethnic Origin

  7. Modifiable • Smoking • Hypertension • Dyslipidemia • Diabetes Mellitus • Obesity • High Calorie Diet • Physical Activity

  8. Why is this important?

  9. Risk Stratification • Primary (and Secondary) Prevention

  10. Risk Stratification • Identifies risks • Important as IHD risks are SYNERGISTIC

  11. Risk Stratification • Calculates ABSOLUTE risk of CVD event in 10 years • Age • Sex • Cholesterol • BP • Smoking

  12. What is “high risk”?

  13. What is “high risk”? • A >20% risk stratification • i.e. Why statin therapy commenced at 20% risk • ?Possibility of commencing “medium” risk?

  14. Artherosclerotic Plaques • From 3rd decade – athroma build up – Angina • From 4th decade – athroma plaque pathology – ACS

  15. Triad of IHD Symptoms ECG Changes Cardiac Markers

  16. Symptoms • Again spectrum of symptoms – dependent on ischaemic pathology and severity Exertional Angina  STEMI

  17. ECG Ischaemic Changes • Can IHD be investigated by performing a 12-lead ECG in a GP practice? • Is a normal ECG at rest diagnostic of a non-ischaemic pathology?

  18. ECG Ischaemia • 12-Lead ECG *During* acute event Inducible Ischaemia • Exercise ECG • Stress ECG/Echo • Myocardial Perfusion Scanning

  19. Cardiac Markers • Should a GP request cardiac markers?

  20. Cardiac Markers - Spectrum

  21. Chest Pain Clinic • Rapid Access Chest Pain Clinic • Part of “National Service Framework” • Nurse Led • Risk Stratification • Perform Inducible Ischaemic Testing • At end of clinic appt – cardiac cause ruled out • OR begin path of treatment and revasculariation

  22. Coronary Angiography

  23. Coronary Angiography • Elective, Semi-Elective or Emergency • Excellent as Diagnostic AND Therapeutic • Whats involved?

  24. Coronary Angiography – for the GP • “I had an angiogram and a stent last week and now I just feel awful......”

  25. Coronary Angiography – for the GP • “I had an angiogram and a stent last week and now I just feel awful......” • “I’m not eating and drinking, and I’m not passing much urine.......”

  26. Coronary Angiography – for the GP • Renal Failure – incidence aprox 10% • High risk group • Contrast Load & dehydration • Check the U&Es if asked to on the TTO!

  27. Coronary Angiography – for the GP • “I had an angiogram last week and now I’ve got this bruise in my groin......”

  28. Haematoma OR Pseudoaneurysm • Difficult to diagnose clinically • Refer for Cardiology Tertiary Centre • Urgent Ultrasound diagnostic

  29. If the risk stratification and modification wasn’t enough..... Acute Coronary Syndromes

  30. ACS - Spectrum NSTEMI  STEMI • Diagnosed on Triad..... • Managed the same?

  31. NSTEMI – ACS protocol and semi-urgent angio +/- re-vascularisation • STEMI – Immediate angio +/- re-vascularisation

  32. Revascularisation • Angioplasty • Stent Insertion • CABG

  33. Post Discharge of ACS Medications • Aspirin 75mg OD • Clopidogrel 75mg OD • Atorvastatin 40/80mg ON • Ramipril – titrated to max dose • Bisoprolol – titrated to max dose • PPI cover – Ranitidine vs. Lansoprazole

  34. Ideal Medications • Aspirin 75mg OD • Clopidogrel 75mg OD • Atorvastatin 80mg ON • Ramipiril 10mg ON • Bisoprolol 10mg OD • Lansoprazole 30mg OD

  35. The Echo • Guidelines state all patients should have an echo post ACS • Reality? • Important to assess LV function post-infarct • Guides: • Management • DVLA guidelines

  36. DVLA guidelines • If untreated ACS (i.e. No stent) • 4 weeks • If treated ACS (i.e. Stented) • 1 week • No driving for 28 days if LVEF <40% • 6 weeks for all HGV!

  37. Cardiac Rehab • 8-12 week programme • Statistically significant at reducing risk factors at 1 year follow-up • 20% dec in re-infarction at 1 year • GP refers if attended Tertiary Cardiology Centre

  38. STEMIs..... Which territory? Which vessel?

  39. ACS on ECGs is EASY Inferior  Anterior  Lateral

  40. Territory - Vessel • Inferior = Right Coronary Artery • Anterior = Left Anterior Descending • Lateral = Left Circumflex

  41. Which territory? Which Vessel?

  42. Which territory? Which Vessel?

  43. Which territory? Which vessel?

  44. STEMIs Overview • Inferior – arrhythmias acutely - well long term • Anterior – LV failure acute and long term • Lateral – generally do well

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