Chronic Medical Conditions

Liz Borlase

Brampton Medical Practice

Chronic medical conditions

QOF and other chronic conditions Designing protocols – two groups

Cardiovascular cases – pairs Challenges of multiple morbidity

Chronic medical conditions

Make a quick list….. or two!

QOF Clinical Indicators Atrial fibrillation CHD HF Hypertension PAD Stroke/TIA DM Hypothyroid Asthma COPD

Dementia Depression Mental Health Cancer CKD Epilepsy Learning Disability Osteoporosis Rheumatoid arthritis Palliative care

Other chronic medical conditions

Addisons Coeliac disease HIV / AIDS Hyperthyroid Inflammatory bowel

disease Irritable bowel

syndrome

Migraine Multiple sclerosis Osteoarthritis Parkinsons disease Polymyalgia Psoriasis …………etc.

Designing protocols

M72 with letter from cardiology confirming new HF on echocardiogram, no other PMH

DH: furosemide 40mg daily, aspirin 75mg daily, and simvastatin 40mg nocte

Letter advises titrating ramipril and bisoprolol How is this to be organised within the PHCT? What? When? By whom? How will you check it is completed?

Heart failure - management

Manage other conditions eg BP Diuretics if needed Lifestyle etc ACE inhibitor or ARB Beta blocker Spironolactone Add ARB ?hydralazine & nitrates, pacing, digoxin

Heart failure - management

Refer for:

Diagnosis Severe heart failure not responding to

treatment Valve disease Pre-pregnancy or pregnant

Heart failure - management

Seattle heart failure model

http://depts.washington.edu/shfm/app.php

Designing protocols

Pick another chronic disease from our list (not QOF)

Design a brief protocol for their follow up What? When? Where? How? By whom?

Tea break

Cardiovascular

Chest pain Palpitations Breathlessness

Ankle swelling Dizziness/faints

Cardiovascular

Cases…..

Case 1

F74 3/52 SOBOE Feels her heart thumping PMH - BP, THR, DM, TIA furosemide, amlodipine, alendronate and

Adcal D3 Irreg pulse ECG AF HR110

Investigations for AF

CVD risk - U&E, eGFR, LFT, Ca, TFT, Chol, HbA1C, FBC

Echo – younger patients, planning for cardioversion, HF, murmur

NOT routinely

Rate control

Over 65 With IHD Contraindications to antiarrhythmic drugs Unsuitable for cardioversion

C.I. to anticoagulation Large atrium, M.S. AF > 12 months Multiple failed attempts Reversible causes e.g. thyrotoxicosis

Rate control

Beta- blocker or rate-limiting calcium antagonist

Add digoxin if needed Target resting HR < 90 Target exercise HR < 200 minus age

Rhythm control

Symptomatic Younger Presenting first time, lone AF Secondary to corrected precipitant CHF

Stroke prevention

CHADS2

CHADS2 Scoring Scheme

Condition Points

C Congestive Heart Failure 1

H Hypertension 1

A Age >75 years 1

D Diabetes 1

S2 h/o Stroke or TIA 2

CHADS2 Scoring Scheme

CHADS2 score

Stroke risk % p.a.

Risk Therapy

0 1.9 Low Aspirin

1 2.8 Moderate Choice

2 4.0 High Warfarin

3 5.9

4 8.5

5 12.5

6 18.2

CHA2DS2-VASc Scoring

Condition Points

C Congestive Heart Failure 1

H Hypertension 1

A2 Age >75 years 2

D Diabetes 1

S2 h/o Stroke or TIA 2

V h/o Vascular Disease 1

A Age 65-74 years 1

S Female 1

Patient Decision Aids

National Prescribing Centre (provided by NICE)

http://www.npc.nhs.uk/patient_decision_aids/pda.php

Starting warfarin for AF

INR target 2.5 No loading dose Yellow book Phone number Patient information including diet Records Safety systems INRstar

Case 2

F42 nurse 3/12 intermittent palpitations Slight dizziness Similar 10y ago on nights PMH – anxiety, depression FH – thyroid disease, DM No current medication

Palpitations - causes

Stress, anxiety Menopause Hyperthyroid Anaemia Caffeine, alcohol Medication Chronic fatigue Hypoglycaemia

Palpitations - questions

Precipitating/relieving factors Regular/irregular Pulse Lifestyle Current stress/mood Weight change Periods

Palpitations - investigations

Bloods ECG

24h tape Event recorder

Case 3

M56 chest pain the day before After food Sweating 20 minutes Chest exam normal, BP 155/95 ECG normal

Chest pain - ?ACS

History of pain > 15 mins N&V, sweating, SOB

Cardiac unlikely if Continuous Unrelated to activity Brought on by breathing Associated dizziness, palpitations, tingling, swallowing sx

Cardiovascular risk factors Previous IHD Previous investigations

Chest pain – ACS

CURRENT PAIN, OR PAIN WITHIN 12h & ECG CHANGES

999 Ambulance GTN, opioids Aspirin ECG Pulse oximetry, oxygen only if sats <94% or if

COPD <88%

Chest pain – ACS

PAIN WITHIN 12h & NORMAL ECG, OR PAIN 12 – 72h

Urgent same-day hospital assessment

PAIN > 72h History, exam, ECG, troponin Then decide….

Stable chest pain

Confirmed IHD - treat or if uncertain Ix

Typical angina - ECG, bloods, aspirin, treat

Atypical angina – ECG, bloods, refer for Ix

Non-anginal chest pain – consider GI and MSK

Stable angina

GTN spray Aspirin, statin, BP, ACE I if DM Beta-blocker or calcium channel blocker Alternatives: long acting nitrates, ivabradrine,

nicorandil

Multiple morbidity

What are the challenges?

Any ideas for addressing these challenges?

Thank-you!

Evaluation forms please….