GP Teaching Afternoon Dr Asif Qasim 24 th September 2014.

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]

[email protected] Available in the coffee break