Ischaemic Heart Disease for the GP

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Ischaemic Heart Disease for the GP

• Chris Tracey
• GPVTS

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What is Ischaemic Heart Disease?

• Artherosclerotic build-up
• Preventing perfusion to myocardium
• Spectrum....

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Ischaemic Spectrum
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Epidemiology

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

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Risk Factors

• Split into Modifiable and Non-Modifiable

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Non-Modifiable

• Increasing age
• Male Gender
• Family Hx
• Ethnic Origin

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Modifiable

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

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• Why is this important?

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• Risk Stratification
• Primary (and Secondary) Prevention

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Risk Stratification

• Identifies risks
• Important as IHD risks are SYNERGISTIC

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Risk Stratification

• Calculates ABSOLUTE risk of CVD event in 10 years
• Age
• Sex
• Cholesterol
• BP
• Smoking

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• What is high risk?

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What is high risk?

• A gt20 risk stratification
• i.e. Why statin therapy commenced at 20 risk
• ?Possibility of commencing medium risk?

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Artherosclerotic Plaques

• From 3rd decade athroma build up Angina
• From 4th decade athroma plaque pathology ACS

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Triad of IHD

• Symptoms
• ECG Changes Cardiac Markers

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Symptoms

• Again spectrum of symptoms dependent on
  ischaemic pathology and severity
• Exertional Angina ? STEMI

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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?

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ECG Ischaemia

• 12-Lead ECG During acute event
• Inducible Ischaemia
• Exercise ECG
• Stress ECG/Echo
• Myocardial Perfusion Scanning

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Cardiac Markers

• Should a GP request cardiac markers?

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Cardiac Markers - Spectrum
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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

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Coronary Angiography
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Coronary Angiography

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

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Coronary Angiography for the GP

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

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Coronary Angiography for the GP

• I had an angiogram and a stent last week and now
  I just feel awful......
• Im not eating and drinking, and Im not passing
  much urine.......

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Coronary Angiography for the GP

• Renal Failure incidence aprox 10
• High risk group
• Contrast Load dehydration
• Check the UEs if asked to on the TTO!

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Coronary Angiography for the GP

• I had an angiogram last week and now Ive got
  this bruise in my groin......

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

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• If the risk stratification and modification
  wasnt enough.....
• Acute Coronary Syndromes

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ACS - Spectrum

• NSTEMI ? STEMI
• Diagnosed on Triad.....
• Managed the same?

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• NSTEMI ACS protocol and semi-urgent angio /-
  re-vascularisation
• STEMI Immediate angio /- re-vascularisation

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Revascularisation

• Angioplasty
• Stent Insertion
• CABG

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Post Discharge of ACS

• Medications
• Aspirin 75mg OD
• Clopidogrel 75mg OD
• Atorvastatin 40/80mg ON
• Ramipril titrated to max dose
• Bisoprolol titrated to max dose
• PPI cover Ranitidine vs. Lansoprazole

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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

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The Echo

• Guidelines state all patients should have an echo
  post ACS
• Reality?
• Important to assess LV function post-infarct
• Guides
• Management
• DVLA guidelines

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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 lt40
• 6 weeks for all HGV!

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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

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STEMIs..... Which territory? Which vessel?
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ACS on ECGs is EASY

• Inferior ? Anterior ? Lateral

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Territory - Vessel

• Inferior Right Coronary Artery
• Anterior Left Anterior Descending
• Lateral Left Circumflex

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Which territory? Which Vessel?
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Which territory? Which Vessel?
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Which territory? Which vessel?
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STEMIs Overview

• Inferior arrhythmias acutely
• - well long term
• Anterior LV failure acute and long term
• Lateral generally do well