Ischaemic Heart Disease (Read Code G3)



Ischaemic Heart Disease (Read Code XE2uV)

▪ Patients with chronic stable angina have twice the mortality of patients without, hence the need for secondary prevention.

▪ ECGs are normal in half of patients with chronic stable angina.

Suspected stable angina

Diagnosis of stable angina can be made on history alone if they have all 3 features.

1. Precipitated by physical exertion

2. Constricting discomfort in front of chest, neck, shoulder, jaw or arm

3. Relief with GTN or rest within 5 minutes

If they have 2 out of 3 and have risk factors for CVD then angina is a real possibility.

If they just have one out of 3 this is unlikely to be angina and especially so if they do not have multiple CVD risk factors. So, a positive diagnosis of non-angina chest pain can be made.

Investigation of suspected stable angina

BP, Pulse, HS, lung fields and peripheral oedema and BNP.

Bloods: FBC, Cr&Es, Lipids, Hba1c and TSH

Then refer RACPC - Non invasive CT coronary angio is now the investigation of choice.

Treatment

1. GTN with 999 rules explanation

2. Beta Blockers e.g. bisoprolol remain 1st line aiming for a pulse rate of less than 60. Safe to use in COPD.

3. CCBs are second line and should be rate limiting e.g. Diltiazem unless a history of heart block or heart failure or Prinzmental’s angina in which case dihydropyridine CCBs e.g. Amlodipine should be used.

4. BB with dihydropyridine CCBs e.g. Amlodipine is fourth line (Avoid using BBs with rate limiting CCBs).

5. If BBs and CCBs contraindicated or not tolerated try a long acting nitrate or Nicorandil.

6. If symptomatic with BBs and CCBs add in a long acting nitrate or nicorandil.

7. Usually specialist initiated Ivabradine or Ranolazine.

8. Secondary prevention measure – aspirin 75mgs a day (unless already on Clopidogrel due to PVD or CVA/TIA) and Atorvastatin 80mg a day. Little evidence ACE or ARB add value if no HF present. Pneumovac and annual flu vac.

Management of suspected acute coronary syndromes

1. Arrange immediate admission to CCU or A&E

2. High flow oxygen ONLY if sats below 94% in non COPD patients BUT in those with COPD and low sats you provide oxygen to achieve sats of 88-92% (NICE 2016)

3. iv Tramadol 50mg over 3 mins OR 2.5 to 5mg of diamorphine OR

morphine 5mg to 10mg (diluted in WFI to 10 ml and given in 1ml doses titrated against patient’s pain)

4. Oral aspirin 300mg stat – decreases mortality.

5. Perform an ECG as soon as possible – this should not delay transfer to hospital

6. Beta blockade within 24hrs and continued for 12 months, longer if evidence of left ventricular dysfunction.

7. Early angioplasty has replaced thrombolysis in most cases. Please note the new rules with respect to the duration of Ticagrelor use in combination with aspirin vary depending upon the type of MI and the type of stent used.

BHF guidance on delayed presentation of suspected ACS

• New onset suspected cardiac chest pain, unstable angina, chest pain within 12 hours with abnormal ECG or ECG unavailable = emergency admission.

 

• Suspected cardiac chest pain within 12 hours with normal ECG. Chest pain with abnormal ECG between 12 and 72 hours ago = Urgent same day assessment

 

• Suspected cardiac chest pain more than 72 hours ago and no complications = rapid access chest pain clinic referral.

What happens at chest pain clinic?

• First line – CT coronary angiography

• Second line – Other non-invasive testing, either MPS SPECT, Stress ECHO, Contrast enhanced MR perfusion or MRI

• Third line – Invasive coronary angiography

• People with confirmed CAD (previous MI, angiography or revascularisation) should be offered either non-invasive tests or Exercise ECG

NB Exercise ECGs should no longer be used to diagnose or exclude stable angina for people without known CAD.

Secondary Prevention of CAD

Non drug therapy

Smoking cessation, lifestyle advice, increased dietary oily fish to > 3x per week. Pneumovac. Annual flu vaccination irrespective of age.

Drug therapy

• Ace inhibitors - (post MI or history of LVD, DM, HT etc) and continue indefinitely. Uptitrate to maximum tolerated dose BUT efficacy in the absence of HF is now being debated.

• Aspirin 75mg - for ‘all’ and continue indefinitely. If allergic use Clopidogrel.

• Ticagrelor and aspirin for 12 month in: NSTEMI or ST elevation MI & stent / medical (no Rx or fibrinolytic Rx) treatment. May be shortened to 6 months if high risk of bleeding and if well tolerated may be extended to 3 years!

• If anticoagulation required Ticagrelor has to be substituted with Clopidorel. Some patients in the first 12 months post event may end up on aspirin, Clopidogrel and Warfarin.

• Offer Clopidogrel instead of aspirin to patients 12 months post MI who have TIA, CVA, PVD etc.

If patients are on an anticoagulant prior to MI then aspirin or clopidogrel is added for 12 months. If a person post-MI is taking or starts an anticoagulant for another condition such as atrial fibrillation (seek specialist advice):

Consider using warfarin and discontinuing treatment with any other anticoagulant such as rivaroxaban, apixaban, or dabigatran.

Use only one antiplatelet drug in addition to the anticoagulant with a PPI.

Use aspirin for people who have had their MI managed medically or have undergone balloon angioplasty or coronary artery bypass surgery.

Use clopidogrel for people where aspirin is contraindicated or not tolerated, and for those who have had percutaneous coronary intervention (PCI) with bare-metal or drug-eluting stents.

Do not routinely offer warfarin in combination with prasugrel or ticagrelor.

After 12 months post-MI, continue anticoagulation and consider the need for ongoing antiplatelet therapy, taking into account: the indication for anticoagulation; thromboembolic risk; bleeding risk; cardiovascular risk; and the person's wishes. If there is uncertainty, seek specialist cardiological advice.

In all of theses cases make sure when adding to the repeat template that you state in the directions when to stop the drug e.g. take one a day until July 2021 and add it as a Major alert.

• Betablockers - for all 12/12 post MI and is not on a betablocker arrange an echo, as betablockers are not indicated in asymptomatic patients with preserved LV function, unless high risk or other compelling reasons for beta-blocker. Bisoprolol is not contraindicated in COPD but should be added cautiously.

• Statins – Most patients post ACS are discharged on Atorvastatin 80mg a day with a ‘treat to target approach’.

Measure total cholesterol, high-density lipoprotein (HDL) cholesterol, and non-HDL cholesterol (total cholesterol minus HDL cholesterol) levels after 3 months of atorvastatin treatment. The aim of treatment is to achieve a greater than 40% reduction in non-HDL cholesterol levels.

If a greater than 40% reduction in non-HDL cholesterol is not achieved:

▪ Discuss adherence and timing of dose with the person.

▪ Reinforce adherence to diet and lifestyle measures.

▪ Consider increasing the dose of atorvastatin (if started on less than 80 mg a day) if the person is judged to be at higher risk of cardiovascular disease (CVD) because of comorbidities or risk score, or using clinical judgement.

If a greater than 40% reduction in non-HDL cholesterol is still not achieved after appropriate dose titrations of atorvastatin, or because dose titration is limited by adverse effects -arrange advice C&B.

• Aldosterone antagonists e.g. Eplerenone or Spironolactone are indicated if symptoms/signs of CCF & LVSD and should be started within 3-14 days of MI, preferably after the ACEI.

• Monitor Cr&E’s as per CCF protocol. Halve dose or stop them if hyperkalaemia is a problem.

• Be aware that CABG offers survival advantages over PCI in patients with multi-vessel disease and are diabetic or patients > 65 years of age

Cardiac re-hab – for all who are suitable, usually arranged prior to discharge following ACS or HF and should start within 2 weeks of discharge.

Finally, ED is common in men post MI.

PDE5 inhibitors are safe to use in stable CHD – once at least 6m post MI.

Remember -

• Avoid PDE5 inhibitors in people treated with nitrates and/or nicorandil, because this can lead to dangerously low blood pressure.

• Nitrates (such as glyceryl trinitrate — GTN) should not be taken within 24 hours of taking sildenafil or vardenafil, or within 48 hours of taking tadalafil.

• PDE5 inhibitors are not recommended for people with low blood pressure, severe heart failure (NYHA III–IV), refractory angina or recent cardiovascular events.

Annual review & the patient pathway

Call and recall are now run by the nursing team. Ensure an appropriate recall has been set at the time of diagnosis.

Key questions the Practice Nurse/ Nurse Practitioner must ask

Use the template to guide you. Here are the key bits…..

Has there been any increase in frequency of your angina or does your angina develop sooner when exertion yourself compared to how things were going at your last review?

1. Do you ever get angina at rest?

1. What do you do if you develop angina?

2. How do you use your GTN spray? (Check 999 rules)

3. Are you more breathless since your last review?

4. What tablets are you taking, when do you take them and do you know what they are for?

5. Have you experienced any side effects.

6. Do you take any ‘over the counter’ medication? (Read code XaF7N OTC aspirin, if they obtain it that way rather than prescribed)

7. Are you under hospital review? When were you last seen and when are you due to be reviewed?

8. Review of medication, lipids, BP, BMI, smoking cessation, importance of flu vac etc to ensure treated to target and appropriate health promotion.

PLEASE NOTE THAT ANY DETERIORATION IN ANGINA CONTROL OR INCREASED BREATHLESSNESS WARRANTS GP REVIEW.

PN/GP annual review

1. The actions for the annual review include; BMI, smoking status/cessation advice, alcohol intake, exercise status & advice, non fasting lipids (cholesterol & LDL), HbA1c and BP.

2. All patients should be reviewed with respect to; symptom control, secondary prevention (appropriate immunisations & timing, drugs at appropriate doses, drug understanding, identifying potential drug side effects, compliance and evidence-based drug review).

3. Recall set and meds re-authorised once all bloods tests are back and review appointment concluded.

Targets at a glance including Q)F 2020/2021

BP

Aspiration BP ................
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