Ischaemic Heart Disease, Atrial Fibrillation and Heart Failure in Primary Care Flashcards
What are the risk factors for IHD?
Non-modifiable risk factors include:
Age
Gender
Family history of CVD
Ethnic background
Modifiable risk factors include:
Smoking.
Low blood level of high-density lipoprotein (HDL) cholesterol.
High blood level of non-HDL cholesterol.
Sedentary lifestyle/lack of physical activity.
Unhealthy diet.
Alcohol intake above recommended levels.
Overweight and obesity.
What are the risk factors for heart failure?
Coronary artery disease (CAD) (the most common type of heart disease) and heart attacks.
Diabetes.
High blood pressure.
Obesity.
Other Conditions Related to Heart Disease.
Valvular Heart Disease.
What are the risk factors for AF?
Age. The older a person is, the greater the risk of developing atrial fibrillation.
Heart disease.
High blood pressure.
Thyroid disease.
Other chronic health conditions.
Drinking alcohol.
Obesity.
Family history.
How is angina diagnosed?
Typical angina presents with all three of the following features:
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
Atypical angina presents with two of the above features.
In addition, atypical symptoms include gastrointestinal discomfort, and/or breathlessness, and/or nausea.
Arrange blood tests to identify conditions which exacerbate stable angina (such as a full blood count for presence of anaemia).
Do not routinely organize a chest X-ray, unless other diagnoses are suspected (such as lung cancer).
How are unstable angina and the STEMIs/NSTEMIs diagnosed?
The ECG may show ST-segment depression, T-wave inversion, or may be normal. High-sensitivity blood tests for serum troponin are used to differentiate between NSTEMI and unstable angina.
How is heart failure diagnosed?
Typical symptoms of heart failure:
Breathlessness — on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea).
Fluid retention
Fatigue
Lightheadedness or history of syncope.
Examine for:
Tachycardia (heart rate over 100 beats per minute) and pulse rhythm.
A laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm).
Hypertension. For more information, see the CKS topic on Hypertension.
Raised jugular venous pressure.
Enlarged liver (due to engorgement).
Respiratory signs such as tachypnoea, basal crepitations, and pleural effusions.
Dependent oedema (legs, sacrum), ascites.
Obesity.
Measure N-terminal pro-B-type natriuretic peptide level.
Arrange a 12-lead ECG.
Chest X-ray.
Blood tests
Urine dipstick for blood and protein.
Lung function tests
What blood tests can be done to assess for underlying causes of chronic heart failure?
Urea and electrolytes, estimated glomerular filtration rate (eGFR), full blood count, iron studies (transferrin saturation and ferritin), thyroid function tests, liver function tests, HbA1c, and fasting lipids. Anaemia and high platelet to lymphocyte percentage (low lymphocyte count) are strong risk factors and prognostic markers of poor outcome.
How is AF diagnosed?
Suspect atrial fibrillation (AF) in people with an irregular pulse, with or without any of the following:
Breathlessness.
Palpitations.
Chest discomfort.
Syncope or dizziness.
Reduced exercise tolerance, malaise/listlessness, decrease in mentation, or polyuria.
12 lead ECG - absent p waves.
What is the management plan in primary care for patients that have angina (stable)?
Symptomatic relief:
GTN spray
Beta-blocker/CCB
BB/CCB contraindicated then monotherapy with:
A long-acting nitrate (such as isosorbide mononitrate).
Nicorandil.
Ivabradine.
Ranolazine.
Secondary Prevention:
Antiplatelets
ACEi
Statin
Anti-hypertensives
What is the management plan in primary care for patients that have AF?
If the onset of atrial fibrillation (AF) was within the last 48 hours:
Urgently admit to an acute medical unit for emergency electrical cardioversion if the person is exhibiting signs and symptoms of haemodynamic instability.
If the person is not exhibiting signs of haemodynamic instability, consider management in primary care.
Assess for the underlying causes and treat them if identified.
Assess for bleeding and stroke risk.
DOAC if indicated.
Rate control with beta-blockers or rate-limiting CCB.
Digoxin is a possible alternative in people with non‑paroxysmal AF if they do little or no exercise, or if other rate-limiting drug options are ruled out because of comorbidities or the person’s preferences.
Consider referral for cardioversion for people whose symptoms continue after their heart rate has been controlled or for whom a rate‑control strategy has not been successful.
What is the management plan in primary care for patients that have heart failure with reduced ejection fraction?
Where symptoms of fluid overload are present, ensure the person has been prescribed a loop diuretic.
Prescribe an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker.
Consider prescribing an antiplatelet to people with atherosclerotic arterial disease (including coronary heart disease).
Consider statin therapy.
Ensure the person is offered an annual influenza vaccine and a once-only pneumococcal vaccination.
What is the management plan in primary care for patients that have heart failure with preserved ejection fraction?
If necessary, prescribe a loop diuretic — up to 80 mg furosemide (or equivalent), to relieve symptoms of fluid overload.
Antiplatelet therapy if indicated.
Statins if indicated.
Ensure the person is offered an annual influenza vaccine and a once-only pneumococcal vaccination.
What is the management plan in primary care for patients that have heart failure with mildly reduced ejection fraction?
Where symptoms of fluid overload are present, ensure the person has been prescribed a loop diuretic.
Prescribe an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker or aldosterone antagonist or sacubitril valsartan.
Consider prescribing an antiplatelet to people with atherosclerotic arterial disease (including coronary heart disease).
Consider statin therapy.
Ensure the person is offered an annual influenza vaccine and a once-only pneumococcal vaccination.
What is the appropriate monitoring and follow-up for patients with stable angina?
Review the person every 6 months to 1 year depending on the stability of their angina and their comorbidities.
Check for ongoing symptoms of angina (at rest or with exercise).
Assess cardiovascular disease risk and identify any modifiable cardiovascular risk factors.
Check for any complications of angina or treatment
Check the person’s heart rate and blood pressure.
Check for signs and symptoms of heart failure.
Screen for low mood or depression.
Review the person’s medication.
Ensure that the person is taking drugs for secondary prevention as appropriate.
What is the appropriate monitoring and follow-up for patients with heart failure?
The follow-up interval should be short (days to 2 weeks) if the person’s clinical condition or drugs have changed, and at least every 6 months if the person’s condition is stable.
Assess and monitor symptoms and signs of heart failure:
Ask about palpitations, shortness of breath, presence of oedema, syncopal and presyncopal symptoms.
Check the person’s pulse rate and rhythm and examine the heart.
Assess fluid status by checking for.
Assess the person’s functional capacity — ask about ability to perform everyday activities using the New York Heart Association classification.
Provide a self-management plan.
Assess the person’s nutritional status.
Review the person’s medications (and ask about possible adverse effects) including over-the-counter preparations.
Ensure immunizations are up-to-date.
Monitor the serum urea, electrolytes, and estimated glomerular filtration rate (eGFR) every 6 months.
