GP Teaching Afternoon Dr Asif Qasim 24 th September 2014

GP Teaching afternoon – Dr Asif Qasim – Update Real world cases Common situations with interface between hospital, GP and community care Questions and discussion – Workshop 1 – Heart Failure / Heart Rhythm – Coffee Break – Workshop 2 – Heart Rhythm / Heart Failure

Case 1: 57 years, female Presented to A+E with 90 minutes ischaemic chest pain at 8am No relevant PMH or regular medications Smoker cigarettes per day ECG – lateral ST depression Treated as Acute Coronary Syndrome Admitted directly to CCU

Case 1: 57 years, female Coronary angiography later that day Right radial approach Severe lesion in the first obtuse marginal Treated with PCI and stent implantation Plan for discharge

Case 1: 57 years, female What treatments reduce her risk of future events? 1.Antiplatelet therapy? 2.Statin? 3.ACE inhibitor? 4.Beta blocker? 5.Cardiac rehabilitation?

Case 1: 57 years, female Cardiac Rehabilitation 1.Smoking cessation 2.Diet – increase in F+V, weight reduction 3.Alcohol moderation 4.Exercise – tailored program 5.Proven reduction in morbidity and mortality

Case 1: 57 years, female Secondary prevention medications: 1.Statin 2.ACE Inhibitor 3.Beta-blocker?

Case 1: 57 years, female Anti-platelet therapy 1.Clopidogrel 2.Prasugrel 3.Ticagrelor

Case 1: 57 years, female Questions?

Case 2: 65M HTN, Ex-smoker – seen in RACPC 3/52Hx Central chest heaviness on walking up hill DHx Amlodipine 5mg OD Resting ECG TWF inferiorly CXR normal Exercise ECG: chest pain and ST depression in stage 2 Bruce Treated with Aspirin, Bisoprolol, Simvastatin Booked for coronary angiography

Angiogram

PCI and Stent to RCA

Nurse led PCI clinic and cardiac rehab There is evidence that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors Increased physical activity and combined dietary changes reduce mortality in coronary heart disease Taylor RS et al (2004). Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med;116:682-92Taylor RS et al (2004). Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med;116:682-92

Case 2:65M Did this patient get good care? Correct investigation? Appropriate treatment?

CG95 NICE CP of recent onset Recent onset chest pain ACS – urgent hospital assessment Exclude non cardiac chest pain Investigation for stable angina Pre-test probability of CAD No use of exercise ECG stress echo, CTA, MPI, Angiography

Risk stratification

CUH RACPC - Less invasive angiography -Greater differentiation between at-risk groups -More CT/ DSE -More interaction between primary and secondary care

CTA Stress echo

OMT vs revascularisation Courage study, NEJM (2007) 2287patients over 5 years >70% stenosis in 1+ epicardial coronary artery and evidence of myocardial ischemia or at least one coronary stenosis of at least 80% and classic angina without provocative testing. Randomly assigned to PCI or optimal medical therapy Success after PCI defined as angiographic success plus the absence of in- hospital myocardial infarction, emergency CABG, or death. Primary outcome - death from any cause and nonfatal myocardial infarction. Secondary outcomes - composite of death, MI / CVA and hospitalization for unstable angina with negative biomarkers

…but in COURAGE All patients had coronary angiography Half the patients had no evidence of ischaemia Less than 10% of screened patients were randomised Patients with critical lesions or strongly positive stress tests were excluded So the real conclusion from COURAGE: Patients with chest pain who might have angina and have moderate coronary lesions with possible ischaemia have the same outcome with PCI as medical therapy

OMT Aspirin and statin First line beta-blocker or Ca antagonist Add other agent or nitrate, nicorandil Emerging evidence for Ronalazine OMT – at least two anti-anginal agents

Prognostic CAD – should be revascularised Obstructive LMCA lesion Proximal three vessel disease Proximal severe LAD lesion Threatened occlusion >10% ischaemia burden on stress echo Consider use of pressure wire and FFR – FAME 1 and 2

CABG or PCI – MDM discussion Offer CABG for Prognostic disease symptoms despite OMT and PCI is not appropriate. Offer PCI for prognostic disease symptoms despite OMT and PCI is appropriate. Consider survival advantage of CABG over PCI for patients who are symptomatic despite OMT with Diabetes with MVD LMCA disease Complex multi-vessel disease

Questions

Case 3: 68 year old female  Atrial fibrillation – rate 110  Echo shows good LV and trivial MR. Dilated left atrium  No exertional symptoms  Aspirin only - No other regular medications  Previous TIA with speech disturbance 12 months previously  Normal CT, ECG and echo at that time

Case 3: 68 year old female  Rate or rhythm control?  Thrombo-embolic risk reduction?  Other tests?

Case 3: 68 year old female New oral anticoagulant drugs:  Dabigatran  Rivoroxaban  Apixaban

Case 3: 68 year old female

Case 4: 82 year old male  Admitted in June due to increasing SOB over 6 days and palpitations  Known IHD, CABG 15 years ago  known LV systolic dysfunction EF=30%  Permanent AF  O/E  AF110  JVP to the ears,  crackles to mid-zone  moderate ankle oedema  ECG AF rate  Baseline creatinine 150, hsTnT 45  CXR CCF, ULD, small right effusion

On admission medications Aspirin75mg Simvastatin 40mg Furosemide 80 mg od Spironolactone 25mg Could not tolerate b blockers Off ACE – hypotension Digoxin 125mcg Treated with iv Furosemide 80 mg bd, good response, lost 6 kg within a week, however creatinine increased Bisoprolol re introduced 1.25 and then 2.5 mg on 18/6

Planning for discharge Prolonged inpatient stay with iv diuretics for 26 days Seen by HF Specialist Nurses EF 30% on echo LBBB on ECG Consideration for CRT-D Advanced planning for end of life care Early FU with HF Specialist Nurses

How could we do better? Improving self care? Better community care? Health technology?

Self Care Patient education and support Understanding Heart Failure Fluid balance Patient self management Fluid intake and Urine output Daily weights Home heart rate and BP Diuretic dose adjustment Identifying exacerbations Red flags and worrying trends Seeking help early HF SN and early clinic access Better advanced planning Discussions about end of life

Community Care All CHS HF admissions to be seen by HF team Early HF SN community FU for all HF discharges Community iv diuretics Avoid admission Early discharge on iv diuretics CHS uniquely placed – national challenge in HF Better advanced planning

Health Technology Telephone clinics Telemetry at home Pulse ECG BP Respiratory rate Weight Device therapy – CRT Improved technology Broader indications Better advanced planning and end of life care

Single-Lead ECG Heart Rate Heart Rate Variability Respiratory Rate Skin Temperature Body Posture including Fall Detection Steps Stress Sleep Staging (Hypnogram) Cloud connectivity Close home monitoring Smart algorithms Home hospital….

Available in the coffee break