Week 11 - Palliative care and IHD, HF, AF

Question 1

Define palliative care (based on WHO definition)

Answer 1

Palliative care is specialised holistic approach to medical care - for people living with a serious and often terminal illness

Offers physical, emotional and practical support:
- Providing relief from the symptoms
- Providing relief from stress of the illness

Goal: improve quality of life for the patient (and their family)

Question 2

List some conditions that might have palliative care needs (think by system)

Answer 2

• Alzheimer’s / Parkinson’s / Amyotrophic Lateral Sclerosis (ALS)
• Stroke
• COPD
• Cardiac diseases e.g. congestive HF
• CKD
• HIV / AIDS
• Cancers
• Major organ failure e.g. liver disease

Question 3

Suggest what is meant by ‘approaching end of life’

Answer 3

Approaching end of life when patients are likely to die within the next 12 months, including those who are expected to diet within a few hours or days

Includes patients with:
- Incurable conditions
- General frailty and comorbidities
- Life threatening acute conditions
- Also applies to extremely premature neonates and patients in a persistent vegatitive state

Question 4

List some symptoms that someone may be at the end of life stage

Answer 4

• Loss of appetite
• Weight loss
• Changes to breathing
• Incontinence
• Skin changes
• Tiredness / fatigue / weakness
• Constipation
• Low mood
• Pain
• Struggling with self-care

Question 5

Roughly outline the following terms (4 pillars of ethics):
- Beneficence
- Non-maleficence
- Autonomy
- Justice

Answer 5

Beneficence - moral duty to promote the course of action they believe is in the best interest of the patient

Non-maleficence - moral duty to do no harm

Autonomy - patient has ultimate decision making responsibility for their own treatment (unless lacking capacity)

Justice - on deciding whether something is ethical, need to consider whether it’s fair, compatible with the law and the patient’s rights

Question 6

What does ReSPECT form stand for?

Answer 6

Re-commended
Summary
Plan for
Emergency
Care and
Treatment

Question 7

Outline the difference between typical and atypical chest pain in angina

Answer 7

Typical symptoms usually include:
- Chest pain described as dull, heavy, tight, or crushing
- Associated arm or jaw pain

Atypical pain is frequently defined as:
- Epigastric / back pain or pain that is described as burning, stabbing
- Pain characteristic of indigestion

Question 8

List some risk factors for ischaemic heart disease

Answer 8

Modifiable:
- Smoking
- Obesity
- Hypertension
- Hypercholesterolaemia
- Diabetes
- Sedentary lifestyle
- Stress

Non-modifiable:
- Male
- Age
- Family history of cardiac deaths

Question 9

List some investigations for ischaemic heart disease (angina and ACS)

Answer 9

• Routine bloods including haemoglobin
• Specific bloods: Troponins and creatine kinase
• ECG
• Echocardiogram (TTE or TOE)
• CT coronary angiography

Other CVS risk factors:
- Lipid levels
- Blood pressure
- Weight and height
- HbA1c for diabetes

Question 10

Outline how ischaemic heart disease (angina and ACS) is diagnosed

Answer 10

First establish whether it is stable (stable angina) or unstable (ACS)

Stable:
- Assessment of risk factors and symptoms
- Often provides a normal cardiovascular examination
- Can use exercise stress tests

Unstable:
- Bloods for troponin and creatine kinase
- ECG

Question 11

Outline some pharmacological management options for angina

Answer 11

First line management
Conservative management - lifestyle measures and secondary prevention medication i.e. aspirin, statin

GTN AND beta-blocker or rate-limiting CCB e.g. Verapamil

Question 12

Outline some of the side effects of GTN spray (used in management of angina)

Answer 12

Side effects:
- Headaches
- Flushing
- Dizziness

Question 13

Outline some medications that may be used in the management of ischaemic heart disease

Answer 13

Prevention of complications:
- Aspirin 75mg

• Consider dual anti-platelet therapy e.g. Clopidogrel
• Consider statins e.g. Atorvastatin 20mg (primary prevention)
• Consider beta blockers / CCB
• Consider nitrites (short or long acting)

Question 14

Outline some causes of development of heart failure (preserved EF and reduced EF)

Answer 14

Preserved EF (fibrous):
- Hypertension
- Diabetes
- Obesity

Reduced EF (poor pumping):
- Previous MI
- Valvular heart disease
- Previous endocarditis
- Congenital heart disease
- Arrhythmias

Question 15

Outline some ways in which heart failure (preserved EF and reduced EF) can be diagnosed

Answer 15

• Bloods for NT-pro BNP
• ECG
• Echocardiogram with ejection fraction (TTE)
  Also:
• Stress test
• CT coronary angiography

Question 16

Outline the management of heart failure generally (conservative and medical)

Answer 16

Conservative:
- Up to date vaccinations
- Smoking cessation
- Reduce alcohol intake
- Optimise comorbidities
- Cardiac rehabilitation programme

Medical treatment:
- ACE inhibitor
- Beta blocker
- Spironolactone
- Furosemide

Procedural or surgical interventions
- May need cardiac resynchronisation therapy if EF is very low (<35%)

Regular follow ups every 6 months

Question 17

Outline some risk factors for developing AF

Answer 17

Acute:
- Sepsis / cardiovascular shock / hypovolaemia
- Alcohol / caffeine

Sustained:
- Hyperthyroidism
- Mitral valve pathology
- Ischaemic heart disease
- Hypertension

Idiopathic

Certain drugs

Question 18

Outline some symptoms that you can have with atrial fibrillation

Answer 18

Most patients with atrial fibrillation are asymptomatic!

Symptoms include:
- Palpitations
- SOB
- Syncope
- Symptoms of associated conditions (e.g. stroke, sepsis or hyperthyroidism)

Question 19

List some investigations for atrial fibrillation and how it is diagnosed

Answer 19

Investigations:
- ECG
- Echo (look for underlying cardiac cause)
- To rule out underlying causes: blood culture, TFTs, blood pressure for hypertension

Diagnosed based on ECG findings:
- Irregularly irregular ventricular rhythm
- Absent P waves
- Narrow QRS complex tachycardia

Question 20

Outline how paroxysmal atrial fibrillation is different from atrial fibrillation and you would further investigate it

Answer 20

Paroxysmal atrial fibrillation presents with episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm
- Episodes can last between 30 seconds and 48 hours
- Can have a normal ECG

Further investigations:
- 24-hour ambulatory ECG (Holter monitor)
- Cardiac event recorder lasting 1-2 weeks

Question 21

Outline the general management of someone with newly diagnosed AF

Answer 21

Rate control
- Beta blockers e.g. Bisoprolol
- CCB e.g. Verapamil

Rhythm control
- Electrical cardioversion or drug cardioversion e.g. Flecainide or Amiodarone
- Long-term rhythm control using medications e.g. Beta blocker (Bisoprolol) or Amiodarone

Anti-coagulation:
- DOACs e.g. Apixaban
- Warfarin

Question 22

Outline how many times GTN spray should be used before seeking emergency help

Answer 22

Take another dose if the pain has not subsided after 5 minutes (2 doses in total)

If the pain has not subsided after 2 doses of GTN, call for emergency help, as this may indicate acute coronary syndrome

Question 23

When should a CHA2DVAS2C score be used

Answer 23

Tool to help decide whether to anticoagulate a patient with AF

Question 24

Outline what CHA2DS2-VASC stands for and how the score influences treatment

Answer 24

Congestive heart failure (1)
HTN (1)
Age > 75 (2)
Diabetes (1)
Stroke, TIA, DVT, PE (2)
Vascular disease (1)
Age 65-75 (1)
Sc sex (F=1)

Male score > 1 = start treatment
Female score > 2 = start treatment

Question 25

When should a HASBLED score be used

Answer 25

Tool to help weight up the risks for anticoagulating a patient with AF

Question 26

Outline what HASBLED stands for, in the context of AF anticoagulation

Answer 26

Hypertension (1)
Abnormal renal / liver function (1 for each)
Stroke previously (1)
Bleed (major previously) (1)
Labile INR (1)
Elderly >65 (1)
Drugs / alcohol (1 for each)