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Cardiology Coronary Artery Disease Or

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  • 1. Cardiology Coronary Artery Disease Or Coronary heart Disease Or Ischeamic heart Disease
  • 2. Coronary Artery Disease
    • Angina
    • Myocardial Infarction (MI) or Heart Attack
    • (cardiac failure)
  • 3. Coronary Artery Disease
    • Leading cause of death in the UK
    • However, as in most western countries, mortality from CAD is falling in the UK
  • 4. Process of CAD
    • Arteriosclerosis- ageing process that begins in youth
    • It involves the deposition of various substances, principally lipids, in the inner layer of the blood vessels- leads to fatty plagues, that protrude into the lumen of the vessel
    • 70% narrowing – symptoms evident
  • 5. CAD
    • Atherosclerosis
      • Partially occluding the lumen
      • Decreased blood supply to the muscle
    • Arteriosclerosis
      • Hardening of the arteries.
      • (refer to your package on PVD)
  • 6. Risk Factors
    • Smoking
    • Hypertension
    • Lack of exercise
    • Hyperlipodaemia
    • Stress
    • Obesity/diet
  • 7. Risk factors
    • Diabetes
    • Family History
    • Gender
    • Age
    • Social class?
  • 8. Angina
    • Where the demand for oxygen by the heart muscle is not met –ischeamia
    • Chest Pain/tightness
      • Central
      • Referred down the arm, pain, heaviness
      • Brought on by effort
      • Eased by rest
      • Exacerbated by eating ‘heavy meals’, cold weather, emotional disturbance
    • Associated with SOB
  • 9. Diagnosis of Angina
    • History
    • ECG changes
    • Exercise Test –to establish the extent and severity of CAD
  • 10. Angina management
    • Medical management- to increase oxygen supply or decrease the demand for oxygen
    • Drug therapy
      • Antiplatelet
      • Nitrates
      • Beta blockers
      • Calcium antagonists
  • 11. Angina management
    • Alter lifestyle- decrease risk profile
    • Surgery –CABG
    • Angioplasty PTCA
    • Cardiac rehabilitation –physio involvement
  • 12. Myocardial Infarction
    • Atherosclerotic plague ruptures and haemorrhages-leading to clot formation and complete occlusion of the vessels lumen
    • If the cardiac muscle is deprived of blood supply-tissue death – infarction
    • Severity and consequences depend on where the blockage occurs
  • 13. MI-Typical presentation
    • Central chest pain, tightness, crushing
    • Radiates down arms, into neck or jaw or abdomen
    • Patient often describes a severe bout of indigestion
    • Sudden, progressive
    • Not relieved by GTN
    • SOB, sweating,faint,weakness,nausea
  • 14. Medical management
    • Admit to hospital ASAP
      • Rapid assessment
        • History
        • ECG-12 lead
        • Serum enzymes or Troponin levels
    • Thrombolytic therapy – streptokinase
    • Pain management - diamorphine
  • 15. Management in Hospital
    • Rest with progressive activity
    • If uncomplicated MI
      • Sit out in 48 hours
      • Home 5-7 days
      • Mobilise around house first week
      • Short walks second week at home
      • 4-6 weeks post MI start cardiac rehabilition.
  • 16. Management in Hospital
    • Complicated MIs have longer in hospital
    • Complications
      • LVF
      • Further chest pain
      • Arrhymias
      • Conduction defects
      • Social circumstances
      • Cardiac arrest
      • Pericarditis
      • PE
      • Psychological problems
  • 17. Cardiac rehabilitation
    • Aim
    • Facilitate physical, psychological and emotional recovery to enable patients to achieve and maintain better health
    • Goals – to improve secondary prevention and improve Q of L.
  • 18. Four Phases of cardiac rehab
    • Phase one – inpatient, activity to counteract bed rest and start adjustment to condition and education
    • Phase two – period between hospital and home reinforce behaviour changes
    • Phase three – issues address in the rest of this talk
    • Phase four – long term maintance phase, self exercise or community programme
  • 19. Standard proposed by the National Service Framework NSF
    • Every hospital should ensure that 85% of people discharged from hospital with a primary diagnosis of acute MI or coronary revascularisation are offered cardiac rehabilitation
  • 20. Comprehensive programme /or exercise alone
    • Systematic review
    • Heart disease is a multi factorial disease
    • Many problems are experienced by people with heart disease not only physical problems but anxiety, and misconceptions about there health
    • Changes to a healthy lifestyle are important
  • 21. Comprehensive programme
    • A combination of the following
      • Exercise
      • Education
      • Psychological help
  • 22. Structure of the programme
    • Great variation in delivery
    • Hospital based
    • Outpatient programme
    • Twice a week
    • 6-10 weeks
    • Low risk patients
  • 23. Multi-professional approach
    • Needed due to multi-factorial nature of coronary heart disease
    • Physiotherapist
    • Nursing staff
    • Dietician
    • OT
    • Clinical psychologist
    • Physician
    • Social worker
    • Pharmacist
  • 24. Who benefits
    • Post MI
    • Post CABG
    • Heart failure
    • PTCA
    • ICD
    • Angina
    • Heart Transplant
  • 25. Result of Research
    • Promotes recovery, physical fitness and psychological
    • Maintain better health
    • Reduce the risk of death
    • Positive effect on lipid profile, BP and smoking cessation
  • 26. Research
    • However, most of the research has been on white middle class males
    • ? Can we generalize to others
  • 27. Women
    • Fewer take up exercise based programmes
    • More women drop out
    • When women do attend their outcomes are equal to males
  • 28. Age
    • 10% are over 75 years
    • Response to exercise similar to younger patients
    • Decrease in re hospitalisation
  • 29. Ethnic minorities
    • People from the Indian subcontinent have a higher mortality
    • No different response to rehab
    • However low attendance rates to programme
  • 30. Role of deprivation
    • Uptake and completion were found to be low among the lower socio-economic groups
    • Studies on inequalities of health have shown that individuals in lower classes have a higher death rate
      • ?related to smoking and diet or uptake of treatment
  • 31. Drop outs
    • High Intensity programmes
    • Poorly organised programmes
    • Access problems
    • More than one MI
    • Smokers
  • 32. Strategies for targeting the underrepresented groups
    • More gender specific information.
    • Housework activities and exercise)
    • Peer support at an early stage
    • Programme characteristics that allow more flexibility and choice to meet patients needs, lower intensity programmes
  • 33. Strategies for targeting the underrepresented groups
    • Environmental factors – physical accessibility flexible working hours and assistance with transport
    • Patients characteristics individual attention rather than group , variety of media, educational material and method of delivery
    • Some evidence that the inclusion of partners and other close family members effects outcome

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