Core Conditions - CHD & HF & Stroke + TIA + Palliative Care Flashcards
what conditions are included in Coronary heart disease
it is a continuum of disease from stable angina to unstable angina to ACS
what is stable angina?
usually occurs predictably with physical exertion or emotional stress, last for no more than 5 minutes (usually less) and is relieved within minutes of rest, as well as sublingual nitrates
what is typical angina
all 3 of the following symptoms
1) chest, neck or jaw tightness exertion
2) precipitated by physical
3) relieved by GTN or rest within 5 minutes
what is atypical angina?
2 of the stable angina symptoms + atypical symptoms (gastrointestinal discomfort +/- SOB +/- nausea)
what is unstable angina?
new onset angina or abrupt deterioration in previously stable angina, often occurring at rest
keypoint = occurs at rest
pathophysiology of coronary heart disease
- Mostly due to atherosclerotic plaques in the coronary arteries
- Plaque breaks up inside the artery
- = blood clot forms on the plaque surface and blocks the blood flow through the coronary artery
- Lack of oxygen to the myocardium – sub-endocardial myocardium is initially affected
- Myocardial necrosis
RF for CHD
- QRISK2 assessment (>10% is significant) – takes into account:
- Age - risk ↑ with age
- Sex - risk ↑ in males
- Ethnicity – more common in Asian/African descent
- Postcode (deprivation ↑ risk)
- Smoking status
- PMHx – e.g. diabetes etc.
- FHx
- BMI
- BP
- Total cholesterol : HDL ratio
what is the diagnostic pathway for angina?
consider which type of angina it is - typical or atypical
if stable angina is suspected –> refer to specialist chest pain service for confirmation
if diagnosis uncertain –> 12 lead ECG
1) pathological Q wave - previous MI
2) LBBB - if new onset = MI until proven otherwise
3) STEMI or NSTEMI
what are some symptom of ACS
acute onset central chest pain which might radiate down to arm & jaw, often occurs with little/no exertion
DM pts might not feel any pain due to neuropathy
associated symptoms
- N+V
- dizziness/syncope
- sweatiness
- SOB
- haemodynamic instability eg BP < 90, thread pulse
- complication - pulmonary oedema
diagnostic pathway for ACS
admission to hospital for confirmation - ECG + troponin level (raised 3-6 hours after MI - 2 weeks)
unless symptoms onset > 72 hours and no complications –> arrange test in primary care
what needs to be included in the counselling on angina
factors that provoke angina - exertion, emotional stress, exposure to cold, eating a large meal
long term complication - stroke, MI, unstable angina
aim to control symptoms
how to use GTN spray/sublingual
lifestyle intervention to reduce CV risk
sexual activity - can continue, GTN helps if symptoms occur, Give 24 hours between phosphodiesterase inhibitors as contraindicated - if taken viagra - do not take GTN and rest
how would you tell patients to administer GTn spray
• Prime: Press nozzle 5 times quickly, spraying into the air. Done the 1st time it’s used and if it has not been used in a week
1) Sit down and rest.
• 2) Remove the plastic cover and hold the bottle upright with your forefinger on top of the grooved nozzle. There is no need to shake the bottle.
• 3) Open your mouth and bring the bottle as close as possible, aiming it under your tongue.
4) Press the nozzle firmly with your forefinger to release the spray under your tongue.
DONOT inhale the spray
5 ) Release the nozzle and close your mouth. Avoid swallowing immediately after taking a dose.
• 6) For a second dose repeat the above steps.
• 7) Replace the plastic cover after use.
what are the side effect of GTN spray
postural hypotension
dizziness
tachycardia
throbbing headache
is a patient with stable angina able to drive a car?
yes - only if symptoms do not occur during rest
what are some primary pharmacological management for stable angina?
GTN spray while waiting for a referral
if pt experience chest pain inform them to
- stop what they are doing and rest
- use GTN
- take a 2nd dose if pain continue after 5 mins
- call 999 if pain still continue 5 mins after 2nd dose of GTN
Beta-blocker/CCB - 1st line for stable again
Isosorbide/Nicorandil/Ivabradine - 2nd line
Secondary prevention
what medications are used for secondary prevention in stable angina
ACE inhibitor if MI +DM
Aspirin 75mg
Statin - reduce CVD risk
hypertension meds
how often should you review a patient with angina?
every 6 months - 1 year
what needs to be review in the annual review of heart failure
assess CV risk & talk about modifiable factors
assess HR, BP, sings and symptoms of heart failure
screen for depression
meds reviews
- compliance
- side effects
- how to use GTN spray
emphasise when to seek medical advice such as acute chest pain
what are the side effects of a statin?
proximal myopathy (pain, tenderness, weakness)
statin should be given at night to avoid weakness and can potentially lead to a fall
definition of heart failure
it is a complex syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment of ventricular filling or ejection
what is classified as Class I (Mild) Heart Failure in the New York Heart Association Functional Classification
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath)
what is classified as Class II (Mild) Heart Failure in the New York Heart Association Functional Classification
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
what is classified as Class III (Moderate) Heart Failure in the New York Heart Association Functional Classification
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
what is classified as Class IV (Severe) Heart Failure in the New York Heart Association Functional Classification
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
what percentage of left ventricular ejection fraction is considered to be in heart failure territory
less than 35-40%
what is classified as Class A in Heart Failure in the New York Heart Association objective Classification
No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
what is classified as Class B in Heart Failure in the New York Heart Association objective Classification
Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
what is classified as Class C in Heart Failure in the New York Heart Association objective Classification
Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
what is classified as Class D in Heart Failure in the New York Heart Association objective Classification
Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.
definition of TIA
acute onset, focal neurological deficit with vascular origin less than 24 hours
definition of stroke
an acute onset, focal neurological deficit with vascular origin longer than 24 hours
where does the poster cerebral artery supply?
occipital portion of the brain both lateral and medial
where does the anterior cerebral artery supply?
the entire of medial anterior portion of the brain + just a bot of laterial pericentric area of the brain
where does the middle cerebral artery supply
parietal part of the brain
what are the different types of stroke>
ischaemic stroke (85%) haemorrhagic (15%) silent stroke - radiological or pathological evidence of an infarction without an attributable history of acute neurological dysfunction
what are the different types of stroke according to the Bamford Classification?
Total Anterior Circulation Syndrome
Partial Anterior Circulation Syndrome
Posterior circulation Syndrome
Lacunar Syndrome
what is the criteria for total anterior circulation syndrome
large cortical stroke in middle/anteior cerebral artery areas
must have all 3 of the following
1) unilateral weakness (+/- sensory deficit) in face, arm or leg
2) homonymous hemianopia
3) higher cerebral dysfunction eg dysphasia, visuospatial disorder
what is the criteria for partial anterior circulation syndrome
partial cortical stroke in middle/anteior cerebral artery areas
must have 2 of the following
1) unilateral weakness (+/- sensory deficit) in face, arm or leg
2) homonymous hemianopia
3) higher cerebral dysfunction eg dysphasia, visuospatial disorder
what is the criteria for posterior circulation syndrome
1 of the following to be included
1) Cranial nerve palsy and a contralateral motor/sensory deficit
2) Bilateral motor/sensory deficit
3) Conjugate eye movement disorder – gaze palsy
4) Cerebellar dysfunction – ataxia, nystagmus, vertigo
5) Isolated homonymous hemianopia
what is the criteria for lacunar syndrome
subcortical stroke due to small vessel disease
no evidence of higher cerebral dysfunction
1 of the following
- unilateral weakness (and/or sensory deficit of face and arm, arm and leg or all 3)
- pure sensory stroke
- ataxic hemiparesis
what are the aetiology/RF of ischaemic stroke
black origin smoking diabetes obesity OCP inc alcohol
- atherosclerosis in carotid arteries
- cardio-emboli
- cerebral small vessel disease
- AF
- vasculitis
- patent foramen ovale
what are the aetiology/RF of haemorrhagic stroke
black origin smoking diabetes obesity OCP inc alcohol
aneurysm rupture bleeding disorder eg haemophilia anticoagulants hypertension cancer amyloid disease av malformations
what are some symptoms of TIA
unilateral sudden onset weakness or sensory loss
dysphagia
ataxia, vertigo or incoordination
syncope
sudden transient loss of vision in 1 eye (amaurosis fugax)
homonymous hemianopia
cranialnerve defects
all symptoms must resolve within 24 hours of the onset of symptoms to be called TIA otherwise it would be classified as a stroke
symptoms of a stroke
think FAST
weakness - suddent loss of strength in the face or limbs
- sensory loss - paresthesia or numbness
- speech problems such as dysarthria
- homonoymous hemianopia
- Dizziness, vertigo or loss of balance
- cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
- inattention/neglet
- confusion, altered level of consciousness and coma
- • Difficulty with fine motor coordination and gait.
• Neck or facial pain
- • Initially flacid and no reflexes then Spasticity +/- clonus, ↑ tendon reflexes
assessment of a stroke?
focused Hx with pt or any witness
- time of onset, activity at onset - critical for tPA (tissue plasminogen activator)
Examin
- A-C incl swallowing assessment
- check BP, HR, O2, Temp
- FAST screening – can you smile, can you raise your arms and keep them there, are you slurring your speech, time
- check CV system for signs of heart failure, arrhythmias, murmurs, valvular heart disease, endocarditis
- neuro exams
- fundoscopy - look for intro-ocular haemorrhage
- arrange ambulance to a stroke specialist unit
what are the investigation for a stroke in a secondary care
- if in ER use ROSIER score (if <0 = likely to be stroke)
- check BM to exclude hypoglycaemia
- ECG
- urgent non-enhanced CT within 1 hr to differentiate between haemorrhagic or ischaemic stroke
management of a suspected stroke in primary care
- While waiting for transfer to hospital:
- Monitor and manage ABC
- Give O2 if sats <95%
- If admission is not appropriate i.e. severe co-morbidities:
- Document
- Discuss with specialist team
- Emergency admission to the nearest hospital with facilities for stroke thrombolysis
management of a suspected stroke in secondary care
Differentiate between ischemic or hemorrhagic stroke CT Head
• Haemorrhagic: refer to neuro
• Ischemic stroke:
• Thrombolysis with tPA (Alteplase IV) – must be given within 4.5 hours of the stroke
• Candidates have a National Institute of Health Stroke Scale score of >24
• Repeat CT head 24h later
• Mechanical thrombectomy
• Aspirin 300mg oral/rectal for 2 weeks or until discharge
• Investigate cause
management of suspected TIA which occured within last 7 days
In the last 7 days/high risk:
• 300mg aspirin immediately (+PPI if appropriate)
• N/A if on 75mg aspirin already
• OR haemorrhagic risk e.g. bleeding disorder, anticoagulanted
• Urgent assessment by specialist stroke team within 24h if high risk (ABCD2 score)
management of suspected TIA which occurred more than 7 days
Over 7 days ago:
• Refer for specialist assessment within 7 days
• Assess for arrhythmias i.e. AF - ABCD2 score (if > 4 = high risk)
• Give information on recognising stroke/TIA and tell them to call 999
• Advise against driving until seen by the specialist
what are the medications used in the secondary prevention of stroke?
1) clopidogrel 75mg +/- aspirin 75 –> if can not tolerate both –> try modified release dipyridamole 200mg
2) Atrovastatin 80mg
3) antihypertensive eg ACEi, CCB etc
4) warfarin/NOAC - deerred start by 14 days with stroke
what are the medications used in the secondary prevention of TIA?
warfarin/NOAC - can start immediately after CT head exclude hemorrhages –> also depends on CHADVAS score and HAS-BLED risk
how would you interact with family and friends of the dying patient
• Offer family members and carers the opportunity for their needs (for example for support and information) to be assessed separately from those of the person receiving palliative care. They may have specific concerns such as:
o Fear of the person dying.
o Anxiety about an emergency occurring (for example what constitutes an emergency and how to deal with it).
o Feelings of inadequacy with regard to caring for the person at home (for example lack of knowledge about how to make the person comfortable or appropriate lifting techniques).
o Suppression of their true emotions in order to protect the person they are caring for.
o Financial worries.
o Altered role and lifestyle.
• Whenever possible and appropriate, invite family members and carers to be involved during clinical encounters and decisions about treatment and care (if this reflects the wishes of the person receiving palliative care).
• The family can be helped by:
o Facilitating communication between the person and their family and health care professionals.
o Recognizing areas of stress in other areas (for example work or coping with children).
o Education to provide the skills and knowledge to provide the necessary aspects of care to enhance the person’s comfort.
o Discussion of pain management to reduce anxiety regarding potential addiction or tolerance.
o Encouraging expression of fears, concerns, uncertainty, and emotional strain.
o Providing information regarding the person’s death and what to expect.
what should be discussed during the end of life plans (Gold Standards Framework)
- Preferred place of care/death
- DNACPR
- Escalation plan/ceiling of care
- Social Hx i.e. friends/family, reglious needs
- Patients wishes: will, funeral
- Advanced care planning
- Lasting power of attorney
- Advance decision to refuse treatment
- Advanced statement
- Sorting out finances
- Medicine review
