CARDIORESPIRATORY Flashcards
What is a patient pathway?
A coordinated and structured plan of care that outlines the expected sequence of events, actions and interventions for patients with a specific health condition
What is the patient pathway for an acute MI?
Symptoms onset
Presentation to A&E or GO
History, examination, vital obs and ECG
Bloods
CXR
Diagnosis of UA/NSTEMI/STEMI
Initial management to stabilise pt and relieve symptoms
Repulsion therapy - Coronary angiogram and PCI or thrombolysis decision
Pharmacology management post-treatment e.g. bb, ACEi and statins as well as lifestyle changes
Ward care
Outpatient care with follow up included rehabilitation programmes e.g. supervise exercise
What are Zola’s triggers to health-seeking?
Interference with work or physical activity
Interferes with social relations
Assigning an arbitrary time limit
Interpersonal crisis e.g. a death
Sanctioning (others telling them to seek help)
What are barriers to rapid diagnosis of MI?
The ‘wait and see’ approach to chest pain
Attendance to GP and not immediately going to A&E
Misinterpretation of ECG
Troponin levels may not rise until up to 12 hours after symptom onset
Atypical presentation particularly women and diabetics
Long wait times
Communication barriers
What are some methods to reduce the delay in treatment of suspected acute coronary syndrome?
Increased public knowledge of symptoms and advice to seek medical attention immediately
NICE guidelines follow for early diagnosis
Fast-tracking admitting system in A+E
Rapid response ambulances that can provide early ECG and administer appropriate meds e.g. nitrates
Quality improvement initiatives
What are the benefits of publicly available performance indicators e.g. mortality following cardiac surgery?
Provide stats about healthcare providers
Informs pt and encourages choice
Transparency, honesty and being open which increases trust in health providers as a result
May identify outliers - can learn from hospitals with lower mortality rates
Standardises care
Regulatory compliance - GMC requires these to be reported
Clear numerical figure
What are the issues with using publicly available performance indicators such as mortality following cardiac surgery?
Risk of over-reliance on performance indicators which may cause providers to feel pressured to prioritise performance targets over other aspects of patient care (stops individualised patient care)
They provide a snapshot of care quality but may not capture the full picture e.g. pt experience
They rely on accurate and complete data collection and reporting but they may be errors or biases
There will always be random variation in mortality rates across hospitals
Must be adjusted for confounders
Incentivising targets may be a pervert practice i..e people avoid complex cases which could increase standardised mortality ratio
May be interpreted wrong by patients
What are the ethnic and gender differences in ischaemic heart disease?
Incidence increases with age
More common in males
Link to FHx and social disadvantages
Black Africans, African Caribbeans and South Asians in the UK are at higher risk of developing high blood pressure or type 2 diabetes compared with White Europeans
What causes the ethnic and gender differences in health and healthcare in IHD?
Different access to healthcare
Differences in health seeking behaviours
Inaccessibility due to language barrier
Genetic susceptibility
Discrimination
Increased smoking prevalence in ethnic minority populations
Oestrogen may have a protective effect against IHD
Risk of type 2 diabetes is roughly double for people with South Asian and African Caribbean background
What was the SABRE study?
Southall and Brent REvisited - a large long term epidemiological study investigating the social, environmental and genetic determinants of health and disease in a multi-ethnic population in the UK.
The aim is to identify the risk factors associated with CVD, t2 diabetes and other chronic disease in different ethnic groups and investigate how genetic, environmental and lifestyle factors interact to influence disease
How are ethnic and gender differences in IHD changing overtime?
Incidence of IHD is increasing in South Asians and Black Africans
The gender gap is narrowing
What are the major risk factors contributing to the incidence of CVD?
Hypertension
Smoking
DM
Hypercholesterolaemia
Obesity
Age
FHx
Male
Ethnicity - South Asian or Black African
Social deprivation
Lack of exercise
Heavy alcohol consumption
Are the major risk factors contributing to the incidence of CVD changing over time?
Smoking is decreasing overall but higher in teenage females
Diet is poor and obesity levels are rising rapidly
Diabetes mellitus prevalence is rapidly increasing
Physical activity is decreasing
Cholesterol levels and hypertension are decreasing due to better treatment
Deprivation is generally decreasing
Overall these changes are decreasing the rates of CHD death
How can an individuals absolute risk of CVD be estimated?
Framingham risk score
QRISK
Reynolds risk score
ASCVD risk estimator
What is the Framingham risk score?
estimates the 10-year risk of developing CVD. It was developed based on data from the Framingham Heart Study and includes age, sex, blood pressure, total cholesterol, HDL cholesterol, smoking status, and diabetes status as risk factors.
What is QRISK?
This is a newer risk prediction tool developed in the UK that estimates the 10-year risk of developing CVD. It includes additional risk factors such as ethnicity, body mass index (BMI), and family history of CVD.
Discuss the evidence associating lifestyle change with CVD risk
Cardioprotective diet - Mediterranean-style diet or DASH diet
Physical activity - at least 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorough intensity aerobic activity
Smoking cessation
Weight management - overweight or obese have a 32% increased risk
Stress management
Alcohol cessation
What can doctors do to help patients make healthy lifestyle changes in regards to CVD?
Provide education
Set realistic and achievable goals
Provide resources e.g. smoking cessation help, exercise programmes,
Monitor progress
Collaborate with other HCP e.g. dieticians
Provide encouragement and motivation
Outline the benefits of smoking cessation on CV health
After 15 years stopping, the risk of MI falls to the same level as someone who has never smoked. The risk falls sharply 1-2 years after cessation ans then declines more slowly after that
Stopping smoking reduces the development of atherosclerosis
If you already have CHD, stoping smoking reduces the risk of all-cause mortality. And reduces the risk or new/recurrent cardiac events
What is primary prevention?
Prevention of a disease before its onset
What is secondary prevention?
Preventing progression or any adverse events once disease has developed
What is tertiary prevention?
Limiting the impact that an adverse event has on health
What are examples of primary, secondary and tertiary prevention in CVD?
Primary - smoking cessation, healthy eating, exercise
Secondary - antiplatelets, statins, antihypertensives
Tertiary - CABG, PCI, thrombolysis
What are the 2 strategies for preventing and managing diseases?
High risk strategy - identifies and targets individuals who are at high risk of developing a particular disease e.g. targeting those with hypercholesterolaemia and providing medication to reduce the risk of CVD
Population strategy - aims to reduce the incidence of a disease across the entire population by implementing broad=based intervention e.g. public health campaigns to encourage health eating
What are the advantages/disadvantages of the ‘high-risk’ approach to preventing and managing diseases?
More effective in preventing disease amongst those most vulnerable
Personalised interventions
Cost-effective
Less effective at reducing overall disease burden in the population
May miss individuals at risk - may not identify everyone as ‘high risk’
Stigmatisation caused by targeting individuals at high risk
Limited impact as only target a small popualtion
What are the advantages/disadvantages of the ‘population’ approach to preventing and managing diseases?
More cost effective and have the potential to impact a larger proportion of the population
Reduces health disparities - does not target populations
More sustainable as often involve changes in policy, environment or social norms which can have a lasting impact on health
Broader impact which reduces overall incidence
Less effecting at preventing disease in high-risk individuals
Less personalised
Limited effectiveness on high risk populations
Costly
What is the prevention paradox?
A preventative measure that brings large benefits to the community offers little to each participating individual
How are risk tables generated?
Researchers collect data from a large population of those at risk of developing CVD and then use statistical models to identify which risk factors are most strongly associated with the development of the disease
They then develop a mathematical model that combines these risk factors to predict an individuals risk of developing the disease over a certain time period
These can be used to inform clinical decision making
Outline a strategy to reduce CVD in the local community?
Community based activities - exercise groups, healthy cooking classes, regular BP and cholesterol screenings
CVD education
Annual QRISK2 scores
Educating members of the public at a younger age to instil healthy lifestyle habits e,g. Physical activity in schools
Prescribing atorvastatin when a QRISK score is >10%
Whats the issue with hypertension?
It increases your risk of:
CVD
ACS
CVA
Cardiac failure
PAD
Aortic aneurysms
Kidney disease
Vascular depentia
