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Cardiovascular cases

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Geoffrey Spurling

on 11 November 2015

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Transcript of Cardiovascular cases

7-15% die in next year
10% if NSTEMI and 15% if STEMI
Predictors = LVEF, residual ischaemia, arrhythmia
When can
Work – usually 6 to 8 weeks
Drive – 2 weeks, 3 months if commercial
Fly – 2 weeks
Statin treatment
NNT 25-50
Should start on dose equivalent to atorvastatin/simvastatin 40mg/day

Ezetimibe – no hard end points
Treatment – Pharmacological:
Anti-platelet therapy
Aspirin (75-100mg)
Continue indefinitely
Use for 12 months after stenting – maybe longer (recent evidence)
If has recurrent STEMI or NSTEMI
Treatment – Pharmacological:
During hospital admission:
CK-MB, troponin
Exercise tolerance test
CI = uncompensated congestive heart failure, cardiac arrhythmia, or noncardiac conditions that severely limit their ability to exercise
Check for diabetes
After hospital admission
+/- blood glucose, thyroid
Specifically look for:
Pulse: arrhythmias
BP: hypertension
JVP, displaced and/or volume loaded apex beat, ankle swelling, S3: Heart failure
Murmurs: papillary muscle rupture/ VSD
Peripheral Pulses: PVD
Calf tenderness/ swelling: DVT
Examination especially for complications:
Acute cardiac disease is the leading cause of death in Australia.

Slightly more than 1% of patients presenting in general practice have a history of ischaemic heart disease
Ischaemic heart disease in Australian general practice
Watch this space
Current assays – serum troponin on arrival (ED or rural general practice) and if negative then redo test 8 hours after the last episode of pain or symptom consistent with Acute Coronary Syndrome (ACS)
If still negative at 8 hours then this can be considered to rule out MI
High sensitivity troponin assays
If negative at >6 hours following last symptom consistent with ACS then this likely rules out ACS.
? Will be able to rule out at 3 hours?
Unreliable predictors of acute coronary syndrome
Relief with GTN (Oesophageal spasm also relieved)
Relief with a GI cocktail eg lignocaine viscous and mylanta
Rest (oesophageal spasm can be relieved by rest)
Normal ECG / Single biomarker
Risk factors for IHD

JAMA 2005; 294(20):2623-2628
The Chest Pain History
QAS – Ambulance
time to re-perfusion in a STEMI is everything stent usually better than lysis
Also Advisable
IV access and morphine
Monitoring (and access to a defibrillator)
Reasonable to try
Possibly harmful unless hypoxic
Mr FS – immediate management of suspected Acute Coronary Syndrome in General Practice
Late Presentation: 10 v 3 hours (NT study inc. urban)
Lack of knowledge regarding symptoms
Role for GPs
Failure to act on symptoms
Primary health care, Acute care facilities, Investigations, Cardiac rehabilitation and CABGs
Streptokinase not advisable
Aboriginal and Torres Strait Islander cardiovascular access to health care:
Aboriginal man aged 30
Aboriginal and Torres Strait Islander peoples in Australia live 15-20 years less than non-Indigenous Australians
IHD disease is the number 1 cause of excess Indigenous death – contributing to approx 27% of the gap
Increased risk factors identified by the Interheart study
Framingham based CV risk calculators underestimate risk by up to 50% esp <35
Who is Mr FS?
Sexuality post MI
Often overlooked
Most people who have had an MI are worried about resuming sexual activity
Concern about coital death
Sexual activity increases metabolic rate 2 or 3 times
Anxiety feeds into depression
If you can walk confidently up two flights of stairs then you are likely to have the physical capacity for sexual relations
ACE inhibition
Useful in the acute treatment of MI
Also useful for long term use post-MI even in the absence of heart failure
Similar savings in mortality to beta blockers
Treatment – Pharmacological:
Beta blockers
Reduce all cause and coronary mortality for up to 2 years
NNT about 50
Continue indefinitely
Treatment – Pharmacological:
Mediterranean diet reduces all-causes mortality after myocardial infarction
Eur J Clin Nutr. 2003 Aug;57(8):1034
NNT=6 according to final report of Lyons diet heart study for prevention of MI/ Death
Circulation. 1999 Feb 16;99(6):779-85.

Stress management / CBT
Recent RCT shows 41 % reduction in fatal and non-fatal cardiovascular events
Arch Intern Med. 2011 Jan 24;171(2):134-40

Probably beneficial = omega 3 fatty acids
Not beneficial = low fat diet, beta carotene, vitamin C or E
Treatment – non-pharmacological cont.
GP management plan
Cardiac rehabilitation program NNT=43
27% reduction in mortality - only 17% get this

Cease smoking
Advice – time of maximum dissonance, Quitline, NRT, pharmacotherapy?
Continued smoking had an adjusted OR of 2.90 (95% CI, 1.35-6.20) for a second MI compared to quitting after the first acute myocardial infarction
Rev Esp Cardiol. 2003 May;56(5):445-51.

Advice from a cardiac nurse NNT=5 for smoking cessation
BMJ. 2003 Nov 29;327(7426):1254-7
Treatment – non-pharmacological:
Heart failure
Complications most likely to present in General Practice
History of presenting complaint
Site and size of infarction,
STEMI or NSTEMI, CK and Troponin levels
Treatment – thrombolysis, angioplasty
New medications
Investigations in hospital
Prior medical history
Smoker 20/day
Infrequent attendance
Prior medications
Post MI: Mr FS comes back 10 days later:
S Yusuf et al INTERHEART Study of 15152 cases vs 14820 controls (including Asia, America, Africa, Middle East) Lancet. 2004 Sep 11-17;364(9438):937-52.
Family history
Hypercholesterolaemia (TC/HDL is best measure)*
Hypertension (most undertreated in Australia)#
Lack of fruit and vegetables
Sedentary lifestyle

*Lancet. 2007 Dec 1;370(9602):1829-39
# Bhatt, JAMA, 2006
Risk factors for ischaemic heart disease
Often need a combination of historical factors + ECG + serial biomarkers (eg troponin)
Can we rule a heart attack in or out based on the history?
Pleuritic (LR 0.2)
Positional (LR 0.3)
Palpation reproduces pain (LR 0.3)
Sharp/ Stabbing (LR 0.3)

0/48 had MI in one series when patient had:
one of 3 Ps + sharp pain + no Hx angina/MI

JAMA 2005; 294(20):2623-2628
The Chest Pain History
JAMA 2005; 294(20):2623-2628
Radiation to right arm (LR 4.7)
Pain with exertion (LR 4.1)
Pain radiates to the left arm (LR 2.3)
Sweating (diaphoresis) (LR 2.0)
Nausea/ vomiting (LR 1.9)
Worse than previous angina or similar to previous MI (LR 1.8)
Described as pressure (LR 1.3)
Advancing age, Male, Hx of coronary disease
The Chest Pain History
Beta blockers,
Calcium Channel Blockers,
Rate Control – AF Management 4

Students may love free food and drink but it would be illegal for drug companies to spend money on you if they could not show their shareholders that they were getting a return on their investment (under the corporation’s act).
It is better to act primarily in the best interests of your patients than in the interests of share-holders of multi-billion dollar companies.
And remember that pharmaceutical company representatives have been highly trained to persuade you and make you like them while they feed you.
…yet their information has been shown in studies to be biased in favour of their product
Most doctors are a hard sell but if you are confident in your ability to resist the spin then you may be more vulnerable than most to persuasion techniques.
Dealing with Drug Companies
Seek Independent Sources – eg NPS RADAR
Recent Level I evidence (systematic review) advises that physicians avoid information from pharmaceutical companies because there has been shown to be no benefit from this information for patients (at best) and some studies suggest an association with harm (at worst)

Recent Level 2 evidence (RCT) suggests medical students should also avoid information from pharmaceutical companies. BMJ 2013;346:f264
Learning about New Drugs (like dagibatran)
Direct thrombin inhibitor
Fixed dose alternative to warfarin for non-valvular atrial fibrillation
150mg b.d./ 110mg b.d.
Reduces stroke/systemic thromboembolism by 0.6% per year compared to warfarin
Overall major bleeding rates are similar to warfarin


But there is no antidote to the bleeding and does dabigatran cause more coronary events compared to warfarin?
N Engl J Med 2013; 368:709-718
Dabigatran – watch this space
MJA 2007; 186(4); 197-202.
Thromboembolism Prevention
Aspirin V. Warfarin
CHADS2 score
Congestive Heart Failure +1
Hypertension +1
Age >75 years +1
Diabetes Mellitus +1
Prior Stroke/ TIA +2

CHADS2 = 0 = aspirin
CHADS2 = 1 = aspirin or warfarin
CHADS2 >1 = warfarin

Warfarin contra-indications:
Recent haemorrhage, malignancy, cirrhosis, peptic ulcer disease, >85 yrs
Thromboembolism – AF Management 3
No evidence of survival benefit, may increase quality of life
Amiodarone, sotalol and DC cardioversion
Radiofrequency ablation shows promise
Rhythm control – AF Management 2
Who wants to zap this?

Salicylates or Warfarin or Neither or Both?

What else should we do?
AF Management 1
Coronary artery disease
Valvular heart disease
Congestive cardiac failure
Electrolyte disturbances, Renal failure
Atrial Fibrillation - precipitants
Irregularly irregular pulse
Is this Atrial Fibrillation?
AF is reported in 1% of GP consultations
Most common arrhythmia according to BEACH data
Atrial Fibrillation
Mr FS (aged 40) returns with palpitations for 3 days
Exercise (+/- cardiac rehab)
Cease smoking
Weight and diet
Fluid restriction (1.5L/day)
Salt restriction
Flu and pneumococcal vaccination
Management plan – what to do if sx worsen
Treatment – non-pharmacological:
not a gold standard investigation for heart failure, but defines function and structure of heart
Cannot get a satisfactory echocardiogram in about 10% of patients
Released by the ventricles in response to pressure and volume overload
High negative predictive value, ie first line “rule out” test
Predicts death and cardiovascular events, including those with no history of heart failure
Monitoring treatment
Specific Investigations
ELFT, lipids, BSL
Q waves, LBBB, T wave inversion, AF, LVH
Rarely normal, but mostly non-specific
Kerley B
pleural effusion
perihilar oedema
Initial Investigations
Under Cardiovascular Resources:
NPS: Targeting ischaemic heart
disease: improving health
outcomes with multiple
Under Emergency Resources:
AFP: Emergency
management of acute
cardiac arrhythmias

Emergency Management of MI in GP
No single element of History rules in or out Acute Coronary Syndrome
IHD risk factors, management
Non-pharmacological and
IHD major problem in Indigenous People
Priorities in Atrial Fibrillation management:
Thromboembolism + rate control > rhythm control
Heart Failure – sometimes difficult to diagnose in GP
Value of diagnostic tests
Management issues

In Conclusion
Educate patient on recognition of sx:
Weigh daily
Pts with symptomatic LVSD have a 5 year survival rate of about 50%
About equal chance of sudden death and pulmonary oedema
Predictors include:
Left Ventricular Ejection Fraction
New York Heart Association
Brain Naturetic Protein
Many have both lung and heart pathology: esp smokers
Examination – JVP, cardiomegaly, S3
Echo, CXR, BNP, spirometry
How do you decide if the patient
with SOB and ankle swelling has HF?
Age, Male
Ischaemic heart disease and MI
Obesity and sedentary lifestyle
Rarer – valve disease, cardiomyopathy, haemochromatosis
Risk factors in Heart Failure
Atrial fibrillation
Resp infection and UTI
Renal failure
Salt Load – eg peanuts/ chips
Calcium Channel Blocker, NSAIDs including COX-II, steroids, Glitazones, TCA, macrolides, cisapride
Check for Heart Failure triggers
HR esp tachycardia, AF***
Peripheral oedema
Weight and BMI
Examination Findings:
Mr FS (aged 50) returns with shortness of breath
0.5% of patients presenting to general practice
many people with heart failure do not present with specific symptoms
most common reason for a medical admission to hospital
Heart Failure
Dr Geoff Spurling
3101 4222/ 3346 4831
Questions and Feedback Welcome
bisoprolol, carvedilol, slow release metoprolol
not CI in asthma, COPD
Loop diuretic
Look for signs of toxicity
Treatment – Pharmacological:
Chest pain
Clinical symptoms and signs associated with acute coronary syndrome
Ischemic heart disease
History, Examination, Investigation
Risk factors
GPs role in management
Issues faced by Indigenous people
Atrial fibrillation
Management issues
Heart Failure
History, Examination, Investigation

Learning Objectives
Mr FS comes back at 40 with palpitations
Mr FS presents with chest pain at lunch time
Increases the likelihood of acute coronary syndrome
Decreases likelihood of acute coronary syndrome
Unreliable predictors of acute coronary syndrome

Abbot et al, Australian Family Physician Vol. 37, No. 4, April 2008
Brown A, Walsh W, Lea T, Tonkin A. What becomes of the broken hearted? Coronary heart disease as a paradigm of cardiovascular disease and poor health among Indigenous Australians. Heart Lung Circ 2005;14:158–62
BMJ. 2008 May 10;336(7652):1058-61
Ong MA, Weeramanthri TS. Delay times and management of acute myocardial infarction in indigenous and non-indigenous people in the Northern Territory. Med J Aust 2000;173:201–4.
Wang Z, Hoy WE. Is the Framingham coronary heart disease absolute risk function applicable to Aboriginal people? Med J Aust 2005;182:66–9.
Terasawa T, Balk EM, Chung M, Garlitski AC, Alsheikh-Ali AA, Lau J, Ip S. Systematic review: comparative effectiveness of radiofrequency catheter ablation for atrial fibrillation. Ann Intern Med. 2009 Aug 4;151(3):191-202.
Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman N, Vitry AI. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med. 2010 Oct 19;7(10)
Take Home Messages
Use Independent sources of information
Avoid drug company information
Be a slow adopter of new drugs
Drazner MH, Rame JE, Dries DL. Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction. Am J Med. 2003;114:431– 437.
Archives of Internal Medicine 2006: 166 (7), 787-796
Risk Factors
Check this out for the latest on statins:
BMJ 2013;347:f7110 doi: 10.1136/bmj.f7110
Full transcript