Ischemic heart disease (angina/chest pain)

Transcription

1 Ischemic heart disease (angina/chest pain) External resurces Stable angina: management NICE guidelines [CG126] Updated :Aug Chest pain f recent nset [CG95] Nvember Management f Stable Angina GP Online 10 steps befre yu refer fr Chest pain, (British Institute f Cardilgy, 2009). What t cnsider in Primary Care befre referring: 1. Take a detailed Clinical and Family Histry 2. Fr chest pain specifically ask: Assciatin with exertin/stress Previus histry f ischaemic heart disease / investigatins/ treatment Timing f last episde f chest pain if within the last 12 hurs please cnsider whether an acute crnary syndrme shuld be excluded Chest pain can be classified as typical / atypical/ nn-anginal when 3 /2 /1 f the fllwing are present cnstricting discmfrt in the frnt f the chest, r in the neck, shulders, jaw r arms precipitated by physical exertin relieved by rest r GTN within abut 5 minutes 3. Cnsider nn cardiac reasns fr chest pain 4. Establish the risk factrs e.g. age (65>), family histry, smking histry, sex (increased prbability in males), diabetes histry, 5. Physical examinatin (including but nt limited t): Pulse rate and rhythm, BP, Presence/absence f murmurs, evidence f peripheral vascular disease, cartid bruits, signs f thyrid disease. If there is evidence f heart failure discuss with medical registrar n call 6. Investigatins (including but nt limited t): FBC, Fasting glucse, HbA1c, lipid prfile, Thyrid functin, resting 12 lead ECG as sn as is practical, renal functin 7. Risk Factr management & lifestyle advice e.g. stpping smking, weight lss, statin (reducing lipids t ttal chl <3.5 mml), 75mg aspirin OD (if nt cntraindicated)

2 It is very imprtant nt t delay treatment, including risk factr management, while awaiting referral r investigatins such as a 12 lead ECG. Stable angina management in primary care invlves: 1) Management f acute anginal pain. Manage with sublingual GTN. Offer safety-netting advice fr prlnged (>20 minutes ) f chest pain 2) Prevent angina attacks. Offer either a beta blcker r a calcium channel blcker as first line. Beta blckers e.g. Atenll mgs d, r metprll mg bd r bisprll mg d. Bisprll is cardiselective and s can be used in COPD patients. Calcium channel blckers e.g. Diltiazem 240mg d, Amldipine 5-10mg d r Verapamil SR 240mg d. If a beta blcker r calcium-channel blcker alne fails t cntrl symptms use a cmbinatin f beta-blcker and dihydrpyridine calcium-channel blcker (e.g. amldipine 5-10mg, feldipine 2.5-5mg d r mdified release nifedipine 30mg d) shuld be used. If the cmbinatin f beta blcker and dihydrpyridine calcium channel blcker is inapprpriate due t intlerance r cntra-indicatin, then the additin f ne f the fllwing culd be cnsidered, if cnfident; a lng acting nitrate (ISMO), Ivabradine, nicrandil r ranlazine. Start with the lwest dse and titrate up. (Use e- cnsult t discuss with a cardilgist if indicated) AVOID using a beta blcker with Verapamil / Diltiazem

3 If a patient has knwn angina but wrsening symptms: Review their medicatin Are they n ptimal and maximal medicatin dse? Are they taking all their medicatin? Please d nt refer fr a GP direct access exercise ECG test in undiagnsed IHD even if lw risk (see NICE guidelines). Refer fr a cardilgy pinin instead e.g. via a RACPC.

4 Referral threshld Referral fr angina is required fr: Cnfirmatin f diagnsis Unstable angina (wrsening pain and at rest) If patient is still symptmatic n maximal anti-anginal medicatin Angina is unlikely if chest pain is: cntinuus r very prlnged and/r unrelated t activity and/r brught n by breathing in and/r assciated with difficulty swallwing Acute chest pain ccurred in the last 12 hurs and nw pain free: Perfrm clinical assessment Refer suspected ACS t the Ambulatry Emergency Care (AEC) If Chest pain is between hurs ag and patient is pain nw free but n prir diagnsis f CHD: Detailed assessment ECG if available Referral based n urgency and clinical judgment t RACP clinic r AEC If Chest pain is between hurs ag and patient is nw pain free pst MI, Pst CABG r Pst PCI Ensure patient is n maximum primary care treatment fr angina Refer t cardilgy utpatients if indicated. Ntes Angiplasty +/- stent reduces mrtality and mrbidity in unstable angina and acute MI. Fr stable angina they nly imprve mrbidity (but nt mrtality) if full medical treatment has failed. CABG can imprve mrtality where there is severe CAD e.g. left main stem disease r 3 vessel disease with impaired LV functin.

5 Criteria fr referral t rapid access chest pain clinic (RACPC is fr diagnsis and patients will be discharged back t GP nce a diagnsis f angina has been made r excluded) 1. New nset f exertinal angina symptms within the past 6 weeks 2. Male > 30 r female > 40 except in exceptinal circumstances Referral threshld Suspected acute MI 999 fr emergency admissin Suspected ACS