Cardiology Coronary Artery Disease Or


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Cardiology Coronary Artery Disease Or

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