clinical update / cardiac rehabilitation maureen geens srn bsc (hons) sponsored by bhf
TRANSCRIPT
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Clinical Update / Cardiac Clinical Update / Cardiac RehabilitationRehabilitation
Maureen Geens SRN BSc (Hons)
Sponsored by BHF
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ObjectivesObjectives
Brief clinical update
Cardiac Rehabilitation
Case Studies
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Inc
ide
nc
e r
ate
(p
er
10
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00
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Q-wave Non Q-wave
1975–1978
1981–1984
1986–1988
1990–1991
1993–1995
1997
Reprinted with permission: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80
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Trends in Acute Coronary Syndrome (ACS)
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Classification of ACS
Myonecrosis
not confirmed
ACS
ECG
ST Elevation No ST Elevation
Troponin
.Aborted MI
STEMI
Myonecrosis
confirmed
STE/ACS
NSTEMI
TnT > 50
TnT+ve -ve
ACS U A
15-49 < 15
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NSTEMINSTEMI
Initial diagnosis Troponin T/I increase and clinical picture.
Management – oral antiplatelets
Percutaneous coronary intervention (PCI) 2-3 days later unless symptoms continue
Discharge 12-24 hours post PCI
Medication: aspirin, clopidogrel/prasugrel, beta-blocker, +/- ACE (angiotensin converting enzyme inhibitor), statin
If PCI successful may drive after 1 week otherwise
4 weeks (DVLA 2008)
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Cardiac Troponin (cTn) I and TCardiac Troponin (cTn) I and T
Best marker of myocardial injury
Normal levels very low
In patients with symptoms compatible with an acute coronary syndrome:
- Increased cTN I or cTn T indicates 4-fold increased risk of death/MI
- Indicates high-risk group who benefit from aggressive management:
Use of enoxaparin/Use of GP IIb/IIIa inhibitor
Early invasive strategy
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STEMISTEMI
Diagnosis ECG, clinical picture
Primary percutaneous coronary angiography (PPCI)
Medication - aspirin, clopidogrel/prasugrel, ACE (angiotensin converting enzyme) inhibitor, beta-blocker, statin
May drive after 1 week
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PLAQUE RUPTURE AND THROMBUS FORMATION
ADP
Platelets
Red blood cell
Fibrinstrands
Smoothmuscle
cells
Fibrouscap
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FRESH ATHEROTHROMBOSIS
Vessel wall
Vessel lumen
Thrombus
Red cell-rich regions
Fibrin-richregions
Atheromatousplaque
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Acute Coronary SyndromesAcute Coronary Syndromes
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BMS DES
… DES are highly effective
Suppression of intimal proliferation
Bare metal stent versus Drug Eluting Stent
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Primary PCI pre / postPrimary PCI pre / post
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Drug TherapyDrug Therapy
All patients who have had an acute MI should be offered treatment with the following drugs
ACE (angiotensin-converting enzyme) inhibitor
Aspirin, Clopidogrel/Prasugrel
Beta-blocker
Statin
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Why Cardiac RehabilitationWhy Cardiac Rehabilitation
What can we do?
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Definition of Cardiac Definition of Cardiac RehabilitationRehabilitation
“ the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible, physical, mental and social conditions, so that people may, by their own efforts preserve or resume when lost, as normal a place as possible in the community.
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Definition of Cardiac Definition of Cardiac RehabilitationRehabilitation
“Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within secondary prevention services of which it forms only one facet”.
Geneva WHO 1993
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National / Local guidelinesNational / Local guidelines
National Service Framework (CHD), (DOH 2000).
BACR (2007)
Strategic Commissioning Development Unit (SCDU 2010)
Local Cardiac Service Review (2010/11)
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Patients referred to our servicePatients referred to our service
Patients post Acute myocardial infarction +/- PPCI or PCIPatients post CABG and Valve surgeryPatients following other cardiac surgery on individual basisElective or emergency PCI patientsPatients with ICDPatients with diagnosis of left ventricular systolic dysfunction
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Service offers an individualised Service offers an individualised assessment to include:assessment to include:
HistoryClinical assessmentRisk factor assessmentLifestyle adviceMedication review and optimising therapyQuality of life and Hospital and Anxiety
Depression (HAD) scoring
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Service offers an Individualised Service offers an Individualised assessment to includeassessment to include
Social and vocational statusExercise programmeAn agreed individualised care management planOngoing clinical assessment, monitoring and
supportEducation facilitation of self managementPro active monitoring and early intervention Psychological support
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Atrial Fibrillation and stroke Atrial Fibrillation and stroke risk reductionrisk reduction
All patients receive a manual pulse check and have a CHADs2 score completed.
Patients in AF will be risk assessed for stroke and with the CHADs2 score will be discussed with the GP
The cardiac nursing team are involved in raising awareness of manual pulse checking and have delivered education sessions to support the ‘stroke strategy’ and risk reduction in AF
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Exercise programmeExercise programme
Provided by specialist cardiac physiotherapist and support therapist
Individual assessment
Functional capacity and METs
Individualised programme
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Method of deliveryMethod of delivery
Individualised Home based
One to one clinic based
Low /medium risk / supervision group setting
High risk / supervision group setting
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Cardiac Service DeliveryCardiac Service Delivery
Home visits
Cardiac nurse clinic
Telephone support
Telehealth monitoring
Heart Manual, angioplasty plan facilitation
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CommunicationCommunication
Directly with GP if there is a clinical concern – telephone / emailCorrespondence with letters / email – dependent on preferred routeAttending MDTsLiaising with practice nurses as necessaryDirect communication with consultants as necessaryDirect links in to acute trust & departmentsCommunication and liaising with all members of the multidisciplinary team to optimise patient care and management
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AuditAudit
The service has a focussed, consistent approach to audit and monitoring outcome measures for all aspects of the service. This includes the input of data into both local and national databases.
National Audit for Cardiac Rehabilitation (NACR)
Athena
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Professional / clinical Professional / clinical supportsupport
The nurses attend clinical mentorship from a cardiologist on a regular basis
Good access to GPWSI cardiology
Supported by the BHF – education etc
Service lead – county meetings, regular 1:1s
Peninsular forums for both CR & HF
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Case Study 1Case Study 1
52 year old male - Smoker
Positive family history
HGV driver
STEMI – PPCI
Discharged
Cardiac rehabilitation referral
Unable to drive HGV until treadmill
approximately 4-6 months, implications financially
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Case Study 2Case Study 2
65 year old male - Farmer
Ex-smoker stopped after MI 8 weeks ago
Positive F/H
Severe triple vessel disease Coronary Artery Bypass Graft (CABG)
Discharged 7 days post operatively cardiac rehabilitation referral
Drive within 6 weeks
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Smoking CessationSmoking Cessation
The cardiac effects of smoking are reversed within 2-3 years of stopping
Five years after stopping, a smokers CV risk is the same as if they had never smoked
Level II/III smoking cessation services
Use of new drugs, such as varenicline (NICE TA123)
Consistent smoking cessation advice from HCPs
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Any Questions?