Cardiology

Coronary Artery DiseaseOr Coronary heart DiseaseOrIscheamic heart Disease

Coronary Artery Disease

Angina

Myocardial Infarction (MI) or Heart Attack

(cardiac failure)

Coronary Artery Disease

Leading cause of death in the UK

However, as in most western countries, mortality from CAD is falling in the UK

Process of CAD

Arteriosclerosis- ageing process that begins in youth

It involves the deposition of various substances, principally lipids, in the inner layer of the blood vessels- leads to fatty plagues, that protrude into the lumen of the vessel

70% narrowing – symptoms evident

CAD

Atherosclerosis Partially occluding the lumen Decreased blood supply to the muscle

Arteriosclerosis Hardening of the arteries.

(refer to your package on PVD)

Risk Factors

Smoking Hypertension Lack of exercise Hyperlipodaemia Stress Obesity/diet

Risk factors

Diabetes Family History Gender Age Social class?

Angina

Where the demand for oxygen by the heart muscle is not met –ischeamia

Chest Pain/tightness Central Referred down the arm, pain, heaviness Brought on by effort Eased by rest Exacerbated by eating ‘heavy meals’, cold

weather, emotional disturbance Associated with SOB

Diagnosis of Angina

History

ECG changes

Exercise Test –to establish the extent and severity of CAD

Angina management

Medical management- to increase oxygen supply or decrease the demand for oxygen

Drug therapy Antiplatelet Nitrates Beta blockers Calcium antagonists

Angina management

Alter lifestyle- decrease risk profile

Surgery –CABG

Angioplasty PTCA

Cardiac rehabilitation –physio involvement

Myocardial Infarction

Atherosclerotic plague ruptures and haemorrhages-leading to clot formation and complete occlusion of the vessels lumen

If the cardiac muscle is deprived of blood supply-tissue death – infarction

Severity and consequences depend on where the blockage occurs

MI-Typical presentation

Central chest pain, tightness, crushing Radiates down arms, into neck or jaw

or abdomen Patient often describes a severe bout

of indigestion Sudden, progressive Not relieved by GTN SOB, sweating,faint,weakness,nausea

Medical management

Admit to hospital ASAP Rapid assessment

History ECG-12 lead Serum enzymes or Troponin levels

Thrombolytic therapy – streptokinase

Pain management - diamorphine

Management in Hospital

Rest with progressive activity If uncomplicated MI

Sit out in 48 hours Home 5-7 days Mobilise around house first week Short walks second week at home 4-6 weeks post MI start cardiac

rehabilition.

Management in Hospital

Complicated MIs have longer in hospital Complications

LVF Further chest pain Arrhymias Conduction defects Social circumstances Cardiac arrest Pericarditis PE Psychological problems

Cardiac rehabilitation

Aim Facilitate physical, psychological

and emotional recovery to enable patients to achieve and maintain better health

Goals – to improve secondary prevention and improve Q of L.

Four Phases of cardiac rehab

Phase one – inpatient, activity to counteract bed rest and start adjustment to condition and education

Phase two – period between hospital and home reinforce behaviour changes

Phase three – issues address in the rest of this talk

Phase four – long term maintance phase, self exercise or community programme

Standard proposed by the National Service Framework NSF

Every hospital should ensure that 85% of people discharged from hospital with a primary diagnosis of acute MI or coronary revascularisation are offered cardiac rehabilitation

Comprehensive programme /or exercise alone

Systematic review Heart disease is a multi factorial

disease Many problems are experienced by

people with heart disease not only physical problems but anxiety, and misconceptions about there health

Changes to a healthy lifestyle are important

Comprehensive programme

A combination of the following Exercise

Education

Psychological help

Structure of the programme

Great variation in delivery

Hospital based Outpatient programme Twice a week 6-10 weeks Low risk patients

Multi-professional approach

Needed due to multi-factorial nature of coronary heart disease

Physiotherapist Nursing staff Dietician OT Clinical psychologist Physician Social worker Pharmacist

Who benefits

Post MI Post CABG Heart failure PTCA ICD Angina Heart Transplant

Result of Research

Promotes recovery, physical fitness and psychological

Maintain better health Reduce the risk of death Positive effect on lipid profile, BP

and smoking cessation

Research

However, most of the research has been on white middle class males

? Can we generalize to others

Women

Fewer take up exercise based programmes

More women drop out When women do attend their

outcomes are equal to males

Age

10% are over 75 years Response to exercise similar to

younger patients Decrease in re hospitalisation

Ethnic minorities

People from the Indian subcontinent have a higher mortality

No different response to rehab However low attendance rates to

programme

Role of deprivation

Uptake and completion were found to be low among the lower socio-economic groups

Studies on inequalities of health have shown that individuals in lower classes have a higher death rate ?related to smoking and diet or uptake

of treatment

Drop outs

High Intensity programmes Poorly organised programmes Access problems More than one MI Smokers

Strategies for targeting the underrepresented groups

More gender specific information. Housework activities and exercise)

Peer support at an early stage Programme characteristics that

allow more flexibility and choice to meet patients needs, lower intensity programmes

Strategies for targeting the underrepresented groups

Environmental factors – physical accessibility flexible working hours and assistance with transport

Patients characteristics individual attention rather than group , variety of media, educational material and method of delivery

Some evidence that the inclusion of partners and other close family members effects outcome