Week 11 - Palliative care and IHD, HF, AF Flashcards
Define palliative care (based on WHO definition)
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)
List some conditions that might have palliative care needs (think by system)
- 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
Suggest what is meant by ‘approaching end of life’
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
List some symptoms that someone may be at the end of life stage
- Loss of appetite
- Weight loss
- Changes to breathing
- Incontinence
- Skin changes
- Tiredness / fatigue / weakness
- Constipation
- Low mood
- Pain
- Struggling with self-care
Roughly outline the following terms (4 pillars of ethics):
- Beneficence
- Non-maleficence
- Autonomy
- Justice
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
What does ReSPECT form stand for?
Re-commended
Summary
Plan for
Emergency
Care and
Treatment
Outline the difference between typical and atypical chest pain in angina
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
List some risk factors for ischaemic heart disease
Modifiable:
- Smoking
- Obesity
- Hypertension
- Hypercholesterolaemia
- Diabetes
- Sedentary lifestyle
- Stress
Non-modifiable:
- Male
- Age
- Family history of cardiac deaths
List some investigations for ischaemic heart disease (angina and ACS)
- 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
Outline how ischaemic heart disease (angina and ACS) is diagnosed
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
Outline some pharmacological management options for angina
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
Outline some of the side effects of GTN spray (used in management of angina)
Side effects:
- Headaches
- Flushing
- Dizziness
Outline some medications that may be used in the management of ischaemic heart disease
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)
Outline some causes of development of heart failure (preserved EF and reduced EF)
Preserved EF (fibrous):
- Hypertension
- Diabetes
- Obesity
Reduced EF (poor pumping):
- Previous MI
- Valvular heart disease
- Previous endocarditis
- Congenital heart disease
- Arrhythmias
Outline some ways in which heart failure (preserved EF and reduced EF) can be diagnosed
- Bloods for NT-pro BNP
- ECG
- Echocardiogram with ejection fraction (TTE)
Also: - Stress test
- CT coronary angiography
Outline the management of heart failure generally (conservative and medical)
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
Outline some risk factors for developing AF
Acute:
- Sepsis / cardiovascular shock / hypovolaemia
- Alcohol / caffeine
Sustained:
- Hyperthyroidism
- Mitral valve pathology
- Ischaemic heart disease
- Hypertension
Idiopathic
Certain drugs
Outline some symptoms that you can have with atrial fibrillation
Most patients with atrial fibrillation are asymptomatic!
Symptoms include:
- Palpitations
- SOB
- Syncope
- Symptoms of associated conditions (e.g. stroke, sepsis or hyperthyroidism)
List some investigations for atrial fibrillation and how it is diagnosed
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
Outline how paroxysmal atrial fibrillation is different from atrial fibrillation and you would further investigate it
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
Outline the general management of someone with newly diagnosed AF
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
Outline how many times GTN spray should be used before seeking emergency help
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
When should a CHA2DVAS2C score be used
Tool to help decide whether to anticoagulate a patient with AF
Outline what CHA2DS2-VASC stands for and how the score influences treatment
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
When should a HASBLED score be used
Tool to help weight up the risks for anticoagulating a patient with AF
Outline what HASBLED stands for, in the context of AF anticoagulation
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)
