Ischaemic Heart Disease for the GP

Chris TraceyGPVTS

What is Ischaemic Heart Disease?

• Artherosclerotic build-up• Preventing perfusion to myocardium

• Spectrum....

Ischaemic Spectrum

Epidemiology

• Cardiovascular disease deaths 240,000 (2004)• IHD deaths 117,000 (2004)

• Mortality decreasing• Incidence stable

• Cost £1.7 billion in healthcare alone

Risk Factors

• Split into Modifiable and Non-Modifiable

Non-Modifiable

• Increasing age

• Male Gender

• Family Hx

• Ethnic Origin

Modifiable

• Smoking• Hypertension• Dyslipidemia• Diabetes Mellitus• Obesity• High Calorie Diet• Physical Activity

Why is this important?

• Risk Stratification

• Primary (and Secondary) Prevention

Risk Stratification

• Identifies risks

• Important as IHD risks are SYNERGISTIC

Risk Stratification

• Calculates ABSOLUTE risk of CVD event in 10 years

1) Age2) Sex3) Cholesterol4) BP5) Smoking

What is “high risk”?

What is “high risk”?

• A >20% risk stratification

• i.e. Why statin therapy commenced at 20% risk

• ?Possibility of commencing “medium” risk?

Artherosclerotic Plaques

• From 3rd decade – athroma build up – Angina

• From 4th decade – athroma plaque pathology – ACS

Triad of IHD

Symptoms

ECG Changes Cardiac Markers

Symptoms

• Again spectrum of symptoms – dependent on ischaemic pathology and severity

Exertional Angina STEMI

ECG Ischaemic Changes

• Can IHD be investigated by performing a 12-lead ECG in a GP practice?

• Is a normal ECG at rest diagnostic of a non-ischaemic pathology?

ECG Ischaemia

• 12-Lead ECG *During* acute event

Inducible Ischaemia1) Exercise ECG2) Stress ECG/Echo3) Myocardial Perfusion Scanning

Cardiac Markers

• Should a GP request cardiac markers?

Cardiac Markers - Spectrum

Chest Pain Clinic

• Rapid Access Chest Pain Clinic• Part of “National Service Framework”

• Nurse Led• Risk Stratification• Perform Inducible Ischaemic Testing

• At end of clinic appt – cardiac cause ruled out• OR begin path of treatment and revasculariation

Coronary Angiography

Coronary Angiography

• Elective, Semi-Elective or Emergency

• Excellent as Diagnostic AND Therapeutic

• Whats involved?

Coronary Angiography – for the GP

• “I had an angiogram and a stent last week and now I just feel awful......”

Coronary Angiography – for the GP

• “I had an angiogram and a stent last week and now I just feel awful......”

• “I’m not eating and drinking, and I’m not passing much urine.......”

Coronary Angiography – for the GP

• Renal Failure – incidence aprox 10%

• High risk group

• Contrast Load & dehydration

• Check the U&Es if asked to on the TTO!

Coronary Angiography – for the GP

• “I had an angiogram last week and now I’ve got this bruise in my groin......”

• Haematoma OR Pseudoaneurysm

• Difficult to diagnose clinically

• Refer for Cardiology Tertiary Centre

• Urgent Ultrasound diagnostic

If the risk stratification and modification wasn’t enough.....

Acute Coronary Syndromes

ACS - Spectrum

NSTEMI STEMI

• Diagnosed on Triad.....

• Managed the same?

• NSTEMI – ACS protocol and semi-urgent angio +/- re-vascularisation

• STEMI – Immediate angio +/- re-vascularisation

Revascularisation

• Angioplasty

• Stent Insertion

• CABG

Post Discharge of ACS

Medications1) Aspirin 75mg OD2) Clopidogrel 75mg OD

3) Atorvastatin 40/80mg ON4) Ramipril – titrated to max dose5) Bisoprolol – titrated to max dose

6) PPI cover – Ranitidine vs. Lansoprazole

Ideal Medications

1) Aspirin 75mg OD2) Clopidogrel 75mg OD

3) Atorvastatin 80mg ON4) Ramipiril 10mg ON5) Bisoprolol 10mg OD

6) Lansoprazole 30mg OD

The Echo

• Guidelines state all patients should have an echo post ACS

• Reality?

• Important to assess LV function post-infarct• Guides:1) Management2) DVLA guidelines

DVLA guidelines

• If untreated ACS (i.e. No stent)• 4 weeks

• If treated ACS (i.e. Stented)• 1 week

• No driving for 28 days if LVEF <40%

• 6 weeks for all HGV!

Cardiac Rehab

• 8-12 week programme

• Statistically significant at reducing risk factors at 1 year follow-up

• 20% dec in re-infarction at 1 year

• GP refers if attended Tertiary Cardiology Centre

STEMIs..... Which territory? Which vessel?

ACS on ECGs is EASY

Inferior Anterior Lateral

Territory - Vessel

• Inferior = Right Coronary Artery

• Anterior = Left Anterior Descending

• Lateral = Left Circumflex

Which territory? Which Vessel?

Which territory? Which Vessel?

Which territory? Which vessel?

STEMIs Overview

• Inferior – arrhythmias acutely - well long term

• Anterior – LV failure acute and long term

• Lateral – generally do well