19 - IHD, AF and Heart Failure Flashcards
What does ischaemic heart disease encompass?
Stable Angina: fixed stenosis of coronary artery
ACS: rupture of stenosis leading to thrombus formation
What are some of the risk factors for IHD?
What are some symptoms of stable angina?
Symptoms:
- Precipitated by physical exertion.
- Constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms.
- Relieved by rest or GTN within about 5 minutes.
- Atypical angina may have GI discomfort, dyspnea, nausea
Suspect ACS:
- Pain that is continuous >15 mins
- Pain at rest
- Pain brought on by breathing.
- Pain with dizziness, palpitations, tingling, or difficulty swallowing
- Haemodynamic instability e.g systolic bp <90
How is angina initially investigated?
Stable: usually on history
- ECG to look for ischaemic changes (e.g Q waves, ST elevation, LBBB)
- FBC to exclude anaemia
- TFTs to exclude hyperthyroidism that can make angina worse
Unstable: urgent referral to cardiology for trop tests and ECG
If you do angina is atypical or the ECG shows ischaemic changes, what investigation is done next?
CT Coronary Angiography
Whilst awaiting diagnostic testing for stable angina, what information should you provide a patient with?
- Prescribe sublingual GTN (see image)
- Consider 75mg aspirin daily until diagnosis
What information and support should you provide for a person with a new diagnosis of stable angina?
- Clearly explain the diagnosis e.g factors that provoke (cold, eating a large meal, emotional stress, exerton), long term course, how it is managed
- Advise the person to seek help if sudden increase in severity or frequency
- Discuss benefits and adverse effects of treatment (e.g flushing, headaches, light headedness)
- Assess cardiovascular risk and manage risk factors
- Tell patient they need to inform the DVLA
- Tell patient they may need to change work if lots of heavy manual labour
- If patients take PDEi for ED tell them not to take their GTN for at least 24 hours of last dose of PDEi. If take PDEi and have angina attack call 999 and do not use GTN. If no ED, take GTN before sexual intercourse to prevent attack
- If angina on small amount of exertion consider in flight oxygen for travel
How is stable angina managed?
Symptomatic drugs, Preventative Drugs, Lifestyle changes
- Sublingual GTN
- Beta blocker or CCB (diltiazem or verapamil)
- If both contraindicated long acting nitrate e.g isosorbide mononitrate or nicorandil
- 75mg aspirin daily for secondary prevention
- Consider ACEi if diabetic and angina
- Offer statin and antihypertensive treatment
What are the side effects of GTN and what advice do you need to give patients when starting this?
- Headaches
- Flushing
- Dizziness
If have to take more than 2 doses and pain still not gone call 999. Wait 5 minutes between doses
If first line drugs do not treat angina, what can be given next?
Second line management
Combine a beta blocker and long-acting dihydropyridine calcium channel blocker
Use nifedipine as otherwise can cause heart block with verapamil
If second line drugs do not work for angina, what management can be done next?
Third line management
- Coronary angiography to look for stenosis
- If stenosis revascularisation with either CABG or PCI
What lifestyle advice should you give someone with angina?
Manage risk factors:
- Smoking cessation
- Glycaemic control
- Hypertension
- Hyperlipidaemia
- Weight loss
- Alcohol intake
When should you refer a person with newly diagnosed angina?
- Pain at rest
- Pain on minimal exertion
- Getting progressively worse despite treatment
How should you follow up patients with established angina?
At every appointment offer info on:
- Managing cardiovascular risk
- Physical exertion including sexual activity
- Driving
- Air travel
- Work
How is chest pain classified and what are some of the causes of this?
- Cause: cardiac or non-cardiac
- Type: localised or poorly localised, pleuritic or non pleuritic
- Cardiac: ACS, stable angina, pericarditis, cardiac tamponade, arrhythmias, myocarditis
- Respiratory: PE, pneumothorax, pneumonia, asthma, pleural effusion
- GI: acute pancreatitis, peptiv ulcer disese, GORD, oesophagitis
- MSK: costochondritis, rib fracture, disc prolapse
- Cancer
- Herpes zoster
- Bornholm’s disese (Coxiesakie Virus)
- Precordial catch (Texidor twinge)
- Psychogenic
If a patient does not require admission for chest pain, what investigations should you carry in primary care?
- ECG
- Blood glucose, lipid profiles, U’s and E’s
- FBC
- TFTs
- CRP and ESR for inflammation or infection
- CXR for heart failure (size) or lung pathology (e.g pleural effusion, cancer, lobar collapse)
What is the early management for unstable angina and NSTEMIs?
- Oxygen: if evidence of hypoxia, pulmonary oedema
- Nitrates: sublingual GTN or IV isosorbide dinitrate to relieve ischaemic pain. If pain continues give morphin by slow IV injection and an antiemetic
- Aspirin 300mg chewed or dispersed
- Fondaparinux sc injection (Antithrombin therapy)
- Clopidogrel 300-600mg or Ticagrelor (P2Y12) 180mg as soon as diagnosis made
- Betablocker when clinically stable unless contraindicated (asthmatic, using CCB, HR<60, Sys BP<100)
- Full clinical history and exam, Trop test, ECG, work out GRACE score and decide if PCI
What is the GRACE score?
Estimates admission-6 month mortality for patients with acute coronary syndrome
Helps you to decide what management to carry out
What drug management is used for secondary prevention after an NSTEMI or unstable angina?
- Aspirin 75mg daily indefinitely
- Ticagrelor 90mg BD for 12 months
- ACEi such as ramipril depending on BP and renal function indefinitely
- Betablocker for 12 months or indefinitely if reduce LV ejection fraction
- Statin 80mg atorvastatin depending on LFTs indefinitely
ATABS
When should you offer PCI to patients with an NSTEMI or unstable angina?
- Immediately if unstable
- If predicted 6‑month mortality above 3.0% carry out CORONARY ANGIOGRAPHY within 72 hours of admission for potential PCA
- If <3.0% give conservative management
How should you manage a STEMI in the early stages?
- Oxygen
- Nitrates and Morphine for ischaemic pain
- Aspirin 300mg chewed or dispersed in water
- Clopidogrel or Ticagrelor
- PCI if can be carried out within 90 minutes of diagnosis with unfractionated heparin
- If PCI cannot be carried out within 90 minutes of diagnosis give unfractionated heparin plus a thrombolytic like alteplase or streptokinase
What is cardiac rehabilitation?
Designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery. Cardiac rehab has three equally important parts:
- Exercise counseling and training
- Education for heart-healthy living e.g smoking and nutrition
- Counseling to reduce stress
What non-pharmacological secondary prevention is offered to patients after an MI?
- Cardiac rehabilitation
- Lifestyle changes e.g smoking cessation, healthy diet, moderate physical activity for 150 minutes a week, losing weight, lowering alcohol
- Reduce any risk fators
What are some of the typical symptoms of a heart attack?
- Pain around the shoulder blades, jaw, neck, arm
- Indigestion
- Discomfort or tightness in the neck or arm
What is preserved and reduced ejection fraction?
- Reduced when below 40%
- Work out by doing SV/EDV x 100%
- Preserved ejection fraction when the left ventricle loses the ability to relax properly
What are some symptoms of heart failure?
- dyspnoea
- cough: may be worse at night and associated with pink/frothy sputum
- orthopnoea
- paroxysmal nocturnal dyspnoea
- wheeze (‘cardiac wheeze’)
- weight loss (‘cardiac cachexia’): may be hidden by oedema
- bibasal crackles on examination
- signs of right-sided heart failure: raised JVP, ankle oedema,hepatomegaly
When should you suspect heart failure?
The ability of the heart to maintain the circulation of blood is impaired
Symptoms:
- Breathlessness (orthopnea, nocturnal, paroxysmal nocturnal dyspnoea)
- Fluid retention (ankle/abdominal swelling, weight gain)
- Fatigue
- Reduced exercise tolerance
- Lightheadedness
Risk Factors
- Coronary artery disease (e.g history of MI, HTN, AF, DM)
- Drugs including alcohol
- Family history of heart failure or sudden cardiac death <40
What investigations should you do if you suspect chronic heart failure?
NT-pro-BNP
(Hormone produced by left ventricular myocardium in response to strain. Very high levels associated with poor prognosis)
Send for transthoracic echocardiogram if raised, time frame depending on how raised
What other investigations in primary care can you do for suspected chronic heart failure?
What are you looking for on examination with chronic heart failure?
Examine for
- Tachycardia >100bpm
- Laterally displaced apex beat
- Heart murmurs
- Hypertension
- Raised JVP
- Enlarged liver
- Respiratory signs like basal crepitations, pleural effusions
- Dependent oedma
- Ascites
- Obesity
ASSESS AND MANAGE ANY UNDERLYING CAUSES OF HEART FAILURE.
What factors can affect natriuretic peptide levels?
This test is very non-specific if positive!!!
If heart failure is suspected but not diagnosed yet, what management can you put in place for a patient?
- Reverse any reversible causes e.g drugs
- If symptoms are severe then prescribe a loop diuretic e.g furosemide, bumetanide
What are the different classifications of heart failure using the NYHA tool?
1 - None
2- Mild
3- Moderate
4 - Severe
What are some of the causes of heart failure?
- Most common: coronary heart disease
What are some of the complications of heart failure?
Cardiac Arrhythmias (e.g AF and ventricular)
Depression
Cachexia
CKD
Sexual Dysfunction
Sudden Cardiac Death
What non-drug treatment should be offered to people with heart failure?
- Offered lifestyle changes e.g smoking cessation, weight control, increasing physical exercise, lowering salt intake to <6g a day if high (do not use salt substitutes high in potassium due to risk of hyperkalemia) and fluid restriction to 1.5-2L/day
- Monitor weight same time a day and report gain of more than 1.5-2.0kg in 2 days to GP
- If acutely unwell stop ACEi, Diuretics, Aldosterone antagonists (sick day rule)
- Contraception and Pregnancy risks should be discussed with women of child bearing age
- Provide sources of info and support e.g NHS, BHF, British Society of Heart Failure
- Offer personalised rehabilitation prgramme
- Offer ICD if HFrEF<35%
When should you refer someone for specialist treatment by a cardiologist and what are some treatments that they may start in specialist care?
- Severe heart failure [NYHA] class IV
- Heart failure that does not respond to treatment in primary care or can no longer be managed in the home setting.
- Heart failure resulting from valvular heart disease.
- Left ventricular ejection fraction of 35% or less
- Pregnancy or planning to get pregnant
- Heart failure plus comorbidity e.g COPD or CKD
How should a person with heart failure be followed up in primary care?
- MDT: including dedicated heart failure nurse, pharmacist and clinician that patient can report change in symptoms to
- Follow up should be days to 2 weeks if the person’s clinical condition or drugs have changed, and at least every 6 months if stable.
- Consider monitoring NT-pro-BNP for response to treatment. Monitor serum urea, electrolytes, and eGFR every 6 months
- Assess and monitor symptoms (see image)
- Assess functional capacity with NYHA scale
- Assess psychosocial needs e.g depression and anxiety
- Assess nutritional status
- Check immunisations up to date (pneumo and flu)
- Check they have a self management plan
How should you manage a person with confirmed heart failure and reduced ejection fraction with drug treatment?
- Loop diuretics: for relief of breathlessness and oedema
- ACEi (or ARB if not tolerated) and BB first line
- Offer aldosterone antagonist (spironolactone or eplerenone) if not Cx (renal impairment or hyperk) if symptoms persist after first line
- If still worsening seek specialist advice to add amiodarone, digoxin, ivabradine
How do you start the first line drugs for HF with reduced ejection fraction?
- Start one drug at a time and titrate up e.g ACEi if diabetic or fluid overload, beta blocker if angina
- Reduces morbidity and mortality
- If already taking beta blocker switch to one licenced for heart failure e.g (bisoprolol, carvedilol)
What is the third line management for heart failure with reduced ejection fraction?
Initiated by a specialist
Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
What classes of drugs should you avoid in treating heart failure with reduced ejection fraction?
- Avoid rate limiting CCBs e.g verapamil, diltiazem, nifedipine as these decrease cardiac contractility. Amlodopine fine
- Also avoid metformin as increased risk of lactic acidosis
- Avoid chemotherapeutic drugs as cardiotoxic
SEE IMAGE
How should you manage a person with confirmed heart failure and preserved ejection fraction with drug treatment?
- Stop any drugs that could worsen or cause heart failure
- Consider loop diuretic like furosemide to relieve fluid retention symptoms e.g breathlessness
- Consider antiplatelet and statin
- Do not give oxygen for breathlessness unless comorbidities that would benefit from it e.g COPD
When would you suspect that a patient is in end stage heart failure?
If at high risk of dying in the next 6-12 months. Symptoms include:
Pain
Breathlessness
Persistent cough
Fatigue
Limitation of physical activity
Depression and anxiety
Constipation
Loss of appetite and nausea
Oedema
Insomnia
Cognitive impairment
What is the Gold Standards Framework Prognostic Indicator Guidelines?
In heart failure specific clinical indicators could be:
- Frequent hospital admissions.
- Poor response to treatment and breathless at rest Class IV
- Presence of cardiac cachexia
- Low serum albumin
- Progressive deterioration in eGFR and hypotension
- Acute deterioration and increasingly frequent hospital admissions from comorbid conditions (such as a chest infection).
- Poor quality of life and dependence on others for most activities of daily living.
- People who are clinically judged to be close to the end of life.
How should you manage patients with end stage heart failure?
- Liaise with a cardiologist and consider switching off ICD
- Explore person’s understanding and provide an appropriate explanation of the situation including realistic goals of care with the person/family
- Ensure patient has advanced care plan
- Provide drugs for symptomatic relief of: breathlessness, pain, anxiety and depression, constipation, nausea, loss of appetite, insomnia
How is symptomatic breathlessness and pain for end stage heart failure controlled?
Breathlessness: optimize standard treatment (e.g diuretics). If this is ineffective, consider prescribing opioid, benzodiazepine, and/or home oxygen.
Pain: cardiac pain so morphine and nitrates
What are the different classifications of AF?
What are some causes of AF?
What are some complications of AF?
- Stroke and Thromboembolism are the main complications
- Heart failure
- Tachycardia-induced cardiomyopathy
What are some signs and symptoms of AF that may present?
Arrhythmia due to irregular disorganised electrical activity in the atria leading to an irregular ventricular rhythm, of around 160-180 bpm
Symptoms:
- Palpitations
- Chest pain
- Shortness of breath
- Dizziness
Signs
- Tachycardia
- Irregular pulse
How is AF diagnosed?
- Conduct an ECG: absent P waves, wavy baseline, irregular ventricular tate, 160-180 bpm
- Conduct 24hr ambulatory ECG or event recorder ECG if suspect paroxysmal AF
What are some other causes of an irregular pulse apart from AF?
- Atrial flutter
- Atrial extrasystoles
- Ventricular ectopic beats
- Sinus tachycardia
- SVTs e.g WPW, AV nodal reentry
- Multifocal atrial tachycardia (seen in severe pulmonary disease)
What is Fast AF and how do you manage this?
AF and HR>100
- If unstable DC cardiovert
- If stable rate control
- Consider reversible causes
In general what is the management of AF in primary care?
- Admit people if unstable
- Manage reversible causes
- Treat arrhythmia with rate control and possible referral for rhythm control
- CHADVASC score for stroke risk
- ORBIT for bleeding risk and manage modifiable risk factors
- Provide info and support groups on AF
When should you refer someone with AF to a cardiologist?
- If rhythm control is appropriate (reversible cause or heart failure caused by AF)
- Rate control treatment fails to control symptoms of AF within four weeks
- Person has valvular disease or left ventricular systolic dysfunction of echocardiography
- WPW or prolong QT on ECG
How should you manage someone with AF in primary care just before commencing pharmacological treatment?
- If onset within last 48 hours and having signs and symptoms of haemodynamic instability (pulse >150, sys bp<90) urgently admit for emergency electrical cardioversion. If stable ask if want to be admitted for immediate cardioversion or treat in primary care
- Find cause and arrange investigations depending on suspicion of cause e.g CXR, transthoracic echocardiogram
- Manage cause, refer if necessary e.g thyroid disease refer to endocrinologist
- Refer to cardiologist for rhythm control if AF has reversible cause or heart failure thought to be caused or worsened by AF
- Calculate HASBLED and CHADVASC scores
- Provide info e.g Atrial Fibrillation Association
How should you pharmacologically treat someone for AF in primary care?
- Rate control: beta blocker (bisoprolol not sotalol as pro-arrhythmic/Torsades) or a rate limiting CCB (e.g verapamil/diltiazem). Can use digoxin if sedentary person as works when heart at rest
- CHADSVASC to see if need anticoagulation with DOAC
- Arrange follow up in a week to review tolerance, symptom control, heart rate, blood pressure
- Consider referral for cardioversion
What is the CHA2DS2VASc score tool?
- Used to asses a person’s stroke risk
- Score of 0 for men or 1 for women is low risk
- Score of 1 is moderate
- Score of 2 or more is high
What is the ORBIT scoring tool?
Identify people at high risk of bleeding who could benefit from increased vigilance and correction of modifiable risk factors
How would you pharmacologically rhythm control patients with AF in secondary care?
- Oral or IV flecainide or amiodarone
- If AF has been present for more than 48 hours electrical cardioversion preferred but should not be attempted until anticoagulated for at least 3 weeks to rule out left atrial thrombus
How should you follow up a patient after starting pharmacological treatment for AF?
Rate control: check in a week. want HR to be between 60-80 at rest and between 90-115 exercising. If they cannot tolerate the drug switch
Anticoagulation: if taking warfarin monitor INR daily until between 2 and 3 on two consecutive occassions. Then do twice weekly until two INRs in range. Then every 12 weeks. If not controlling consider changing to DOAC. Check drugs table for DOAC monitoring
How should you review a patient with AF annually?
- Check for symptoms of AF at rest and on exercise, checking heart rate
- Review medication (up dose or refer if necessary)
- Reassess CHADVASC and ORBIT
- Assess and maanged CVD risk
- Assess and manage complications of AF
What are some causes of fatigue?
What are some risk factors for fatigue?
- Female
- Lower socioeconomic status
- Lower physical activity levels
How should you assess a person presenting with tiredness/fatigue?
- Ask what the person means by being tired
- Onset, duration, severity and precipitating factors
- Sleep quality, quantity, patterns, sleep hygeine, snoring, nocturia, restless legs
- Any stressful life events
- Housing situation and possibility of CO poisoning
- Symptoms of depression or anxiety
- Any chronic conditions e.g COPD
- Any medication, including herbal and OTC
- Examine the person including mental state exam and assess mood
What are some red flags you should look for when a person presents with chronic tiredness?
- Significant weight loss (5% of body weight in 6-12 months) could mean malignancy, Addisons, diabetes, hyperthyroidism
- Fever, night sweats, lymphadenopathy could mean HIV, TB, hepatitis
- Muscle or joint pains
- Localising or focal neurological signs could mean MS or brain tumour
- History of travel and bites
What is Chronic Fatigue Syndrome (CFS) and how is it diagnosed?
Persistent, recurrent debilitating fatigue that is not lifelong, no the result of ongoin exertion, not alleviated by rest, not explained by other medical conditions and results in a substantial reduction in activity
Reconsider CFS if none of the following are present: post exertional fatigue, cognitive difficulties, sleep disturbance, chronic pain
What are some risk factors for CFS?
- Female
- Higher BMI
- Lower socioeconomic status
- Physical or psychosocial comorbidity
What investigations should you carry out if a patient presents with tiredness?
If 1 month or longer: FBC, ESR, CRP, LFTs, Renal Function, HbA1C, IgA tissue transglutaminase
If 3 months or longer: Urinarlysis, CK
Case-by-case basis: Bone chemistry and Myeloma screen, Vit D level, Infectious mononucleosis, HIV, Hepatitis, CXR and sputum samples for TB
When should you refer an adult with tiredness to secondary care?
- If confirmed underlying cause cannot be managed in primary care
- CFS service for posible CBT
How should you manage adults with tiredness/fatigue in primary care?
- Manage any underlying causes and contributory factors
- Offer sources of info e.g NHS info
- Manage any associated stress, anxiety or depression
- Offer advice on sleep hygeine
- Limit length of rest periods to 30 minutes
- Eat healthy, balanced diet
- Use relaxiation techniques e.g breathing work
What are some warning signs of worsening heart failure?
If a patient needs to be on a beta blocker and CCB for angina, what is important to note?
Use nifedipine as verapamil and b-blocker together can cause complete heart block
What is the issue with giving nitrates for angina?
Nitrate Tolerance!
Also risks with ED medication
What is the third line management for heart failure with reduced ejection fraction?
Initiated by a specialist
Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
What is important to note about the use of loop diuretics in heart failure?
Only improve symptoms not mortality
ACEi, BB and Aldosterone antagonists all improve mortality
If you have a patient with a CHADVASC score of 0 what is important to check?
Ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.
