1. Ischaemic Heart Disease for the GP Chris Tracey GPVTS

2. What is Ischaemic Heart Disease? Artherosclerotic build-up Preventing perfusion to myocardium Spectrum....

3. Ischaemic Spectrum

4. Epidemiology Cardiovascular disease deaths 240,000 (2004) IHD deaths 117,000 (2004) Mortality decreasing Incidence stable Cost £1.7 billion in healthcare alone

5. Risk Factors Split into Modifiable and Non-Modifiable

7. Non-Modifiable Increasing age Male Gender Family Hx Ethnic Origin

8. Modifiable Smoking Hypertension Dyslipidemia Diabetes Mellitus Obesity High Calorie Diet Physical Activity

9. Why is this important?

10. Risk Stratification Primary (and Secondary) Prevention

11. Risk Stratification Identifies risks Important as IHD risks are SYNERGISTIC

13. Risk Stratification Calculates ABSOLUTE risk of CVD event in 10 years 1)Age 2)Sex 3)Cholesterol 4)BP 5)Smoking

14. What is “high risk”?

15. A >20% risk stratification i.e. Why statin therapy commenced at 20% risk ?Possibility of commencing “medium” risk?

16. Artherosclerotic Plaques From 3 rd decade – athroma build up – Angina From 4 th decade – athroma plaque pathology – ACS

17. Triad of IHD Symptoms ECG Changes Cardiac Markers

18. Symptoms Again spectrum of symptoms – dependent on ischaemic pathology and severity Exertional Angina  STEMI

19. 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?

20. ECG Ischaemia 12-Lead ECG *During* acute event Inducible Ischaemia 1)Exercise ECG 2)Stress ECG/Echo 3)Myocardial Perfusion Scanning

21. Cardiac Markers Should a GP request cardiac markers?

22. Cardiac Markers - Spectrum

23. 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

24. Coronary Angiography

25. Elective, Semi-Elective or Emergency Excellent as Diagnostic AND Therapeutic Whats involved?

26. Coronary Angiography – for the GP “I had an angiogram and a stent last week and now I just feel awful......”

27. 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.......”

28. 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!

29. Coronary Angiography – for the GP “I had an angiogram last week and now I’ve got this bruise in my groin......”

31. Haematoma OR Pseudoaneurysm Difficult to diagnose clinically Refer for Cardiology Tertiary Centre Urgent Ultrasound diagnostic

32. If the risk stratification and modification wasn’t enough..... Acute Coronary Syndromes

33. ACS - Spectrum NSTEMI  STEMI Diagnosed on Triad..... Managed the same?

34. NSTEMI – ACS protocol and semi-urgent angio +/- re-vascularisation STEMI – Immediate angio +/- re- vascularisation

35. Revascularisation Angioplasty Stent Insertion CABG

36. Post Discharge of ACS Medications 1)Aspirin 75mg OD 2)Clopidogrel 75mg OD 3)Atorvastatin 40/80mg ON 4)Ramipril – titrated to max dose 5)Bisoprolol – titrated to max dose 6)PPI cover – Ranitidine vs. Lansoprazole

37. Ideal Medications 1)Aspirin 75mg OD 2)Clopidogrel 75mg OD 3)Atorvastatin 80mg ON 4)Ramipiril 10mg ON 5)Bisoprolol 10mg OD 6)Lansoprazole 30mg OD

38. The Echo Guidelines state all patients should have an echo post ACS Reality? Important to assess LV function post-infarct Guides: 1)Management 2)DVLA guidelines

39. 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!

40. 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

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

42. ACS on ECGs is EASY Inferior  Anterior  Lateral

44. Territory - Vessel Inferior = Right Coronary Artery Anterior = Left Anterior Descending Lateral = Left Circumflex

46. Which territory? Which Vessel?

48. Which territory? Which vessel?

49. STEMIs Overview Inferior – arrhythmias acutely - well long term Anterior – LV failure acute and long term Lateral – generally do well