PREVENTIVE AND REHABILITATIVE MANAGEMENT OF ACUTE CORONARY SYNDROMES (NSTEMI, STEMI, PCI)

Size: px

Start display at page:

Download "PREVENTIVE AND REHABILITATIVE MANAGEMENT OF ACUTE CORONARY SYNDROMES (NSTEMI, STEMI, PCI)"

Alexina Reed
5 years ago
Views:

1 PREVENTIVE AND REHABILITATIVE MANAGEMENT OF ACUTE CORONARY SYNDROMES (NSTEMI, STEMI, PCI) Dato Dr. Balachandran Kandasamy Institut Jantung Negara 12 th November 2016

2 KEY MESSAGES 1. Initiate a long-term management plan for all patients with acute coronary syndromes (ACS) 2. Consider guideline-recommended medicines for all patients with ACS 3. Identify risk factors and refer all patients with ACS to secondary prevention programs 4. Communicate management plan to the patient, carers and the community healthcare providers

3 INITIATE A LONG-TERM MANAGEMENT PLAN FOR ALL PATIENTS WITH ACUTE CORONARY SYNDROMES Patients with ACS are at high risk of further cardiovascular events and death. For long-term management a medicines management plan, a chest pain action plan and a comprehensive cardiovascular risk reduction program are recommended. Communicate this plan to the patient and/or carer and their community healthcare providers.

4 INITIATE A LONG-TERM MANAGEMENT PLAN FOR ALL PATIENTS WITH ACUTE CORONARY SYNDROMES i. Medicines management plan ii. Chest pain action plan iii. Identify risk factors and refer to secondary prevention programs

5 i. Medicines Management Plan Consider starting guideline-recommended medicines in hospital before discharge. Provide all patients with a written medicines management plan which includes: a list of all medicines the dose and plan for any required dose titration intended duration of therapy the purpose and potential benefits of therapy potential adverse effects of each medicines schedule for follow-up and monitoring access to consumer medicine information.

6 INITIATE A LONG-TERM MANAGEMENT PLAN FOR ALL PATIENTS WITH ACUTE CORONARY SYNDROMES Communicate the management plan to patients and all those involved in care

7 ii. Identify Risk Factors And Refer To Secondary Prevention Programs Discuss the warning signs of a heart attack and an immediate plan of action, including the use of short-acting nitrates and the importance of dialling 000 if pain is not relieved. Each patient should receive a written chest pain action plan which includes: warning signs of a heart attack when and how to take the short-acting nitrate self-administration of aspirin, unless contraindicated instructions to call an ambulance if chest pain or discomfort lasts longer than 10 minutes additional instructions for patients who live in rural and remote locations

8 iii. Identify Risk Factors And Refer To Secondary Prevention Programs Actively refer to, and encourage attendance at, secondary prevention and cardiac rehabilitation programs. Provide education and set goals on lifestyle factors, including advice on smoking cessation where appropriate. Assess for depression and level of social support.

9 CONSIDER GUIDELINE-RECOMMENDED MEDICINES FOR ALL PATIENTS WITH ACS The combination of antiplatelet agents, a beta blocker, a statin and an angiotensin-converting enzyme (ACE) inhibitor is recommended for most patients, unless contraindicated. All four drug classes have been proven to reduce subsequent cardiac events and death. Individualise therapy according to known comorbidities, risk of adverse effects and clinical judgement. If the guideline-recommended therapy is not indicated for an individual, document this and the reason(s) why in the patient s medical record and long-term management plan.

12 IDENTIFY RISK FACTORS AND REFER ALL PATIENTS WITH ACS TO SECONDARY PREVENTION PROGRAMS Provide patients with a self-management plan before discharge, as patients and their families/carers are focused on promoting health and are more receptive to medical interventions immediately after an acute event. The plan should include advice on lifestyle changes that will reduce the risk of further cardiac events (including quitting smoking, good nutrition, moderating alcohol intake, regular physical activity and weight management), as appropriate. All patients should have access to, and be actively referred to, comprehensive secondary prevention and cardiac rehabilitation programs.

13 Refer All Patients to Their Closest Available Cardiac Rehabilitation Program Cardiac rehabilitation is a proven effective intervention. Attendance at cardiac rehabilitation outpatient programs reduces risk of further cardiac events. Cardiac rehabilitation, including advice about physical activity, improves individual health outcomes. Patients who participate in cardiac rehabilitation programs can improve physical activity, weight loss, smoking cessation, blood lipid levels and blood pressure control.

14 PRINCIPAL GOAL: CARDIAC REHABILITATION To lessen the risk of future coronary events, control symptoms arising from coronary disease and to return the patient to optimal or previous functional status Patient population predominantly confined to post MI, bypass graft, angioplasty & stable angina but must also be made available to heart failure patients. M.A CALDWELL & K. DRACUP, JOURNAL OF CARDIOPULMONARY REHABILITATION 2001

15 THE FOUR PHASES OF CARDIAC REHABILITATION Phase I Before discharge from hospital Phase II Early post-discharge period Phase III 4-6 weeks after an acute cardiac event Phase IV Long term maintenance of changed behaviour

16 PHYSIOTHERAPY IN IJN Inpatients & Outpatients Acute Care Cardiac Rehabilitation Programme I & II Ward Gym Patient Referral Exercise Programme

17 OTHER BENEFICIAL EFFECTS OF CARDIAC REHABILITATION FOR PATIENTS WITH CHD Improves Control of Dyslipidemia in secondary prevention B.L.,Verges et al Journal of Cardiopulmonary Rehabilitation, 1998 Weight loss intervention P.D., Savage et al Journal of Cardiopulmonary Rehabilitation, 2002 Post Myocardial infarction or CABG J. Redfern, Journal of Physiotherapy, 2011 Stable Chronic Heart Failure- can achieve significant improvement in functional capacity from a low intensity exercise training program. R. Belardinelli et al J Am Coll Cardiol, 1995 Exercise training improves exercise tolerance and LV function in patients with Dilated Cardiomyopathy K.Q., Stolen et al J Am Coll Cardiol, 2003

WHO Definition of Cardiac Rehabilitation The Sum of Activities required to ensure the patients, the best possible physical, mental and social conditions, so that they may (by their

18 WHO Definition of Cardiac Rehabilitation The Sum of Activities required to ensure the patients, the best possible physical, mental and social conditions, so that they may (by their own efforts), resume and maintain as normal a place as possible in the community F.J.Brannon et al:cardiopulmonary rehabilitation: Basic Theory and Application 2 nd Ed, pg.148(1993)

CARDIAC REHABILITATION PHASE I Inpatient recovery program (ICU/ WARDS/ GYM) Post MI start 2-4 days after hospitalized Post surgery start 1-2 days after surgery Lasts for 2-3 weeks Intensive medical

19 CARDIAC REHABILITATION PHASE I Inpatient recovery program (ICU/ WARDS/ GYM) Post MI start 2-4 days after hospitalized Post surgery start 1-2 days after surgery Lasts for 2-3 weeks Intensive medical supervision Low intensity exercise ( METS) 60% - 70% of MHR Exercise done daily- shoulder and arm exercises, gentle trunk exercises, ambulating short distances, gym & a flight of stairs without adverse symptoms

24 CARDIAC REHABILITATION PHASE II (IJN) Out patient convalescence program Starts within 2-3 weeks of discharge Lasts for 3 months Referred by physician and medically supervised Light to moderate exercise (2-5 METS) 65% - 75% of MHR 3 times per week 14/11/

25 PHYSIOTHERAPY & REHABILITATION DEPT., IJN, CRP PHASE II 1. Strengthening Exercises Assessment 5. Stretching and Cool down Circuit Training 2. Endurance Exercise (stationary bike or treadmill) Re-assessment 4. Exercise tolerance (walking for 6 mins) 3. Exercise Tolerance( step board) Patient Education 14/11/

26 Warm up/cool down CRP PHASE II -IJN - A gradual and progressive warm-up of 10 to 15 mins. incorporating mobility and stretching *Strenuous exertion without previous warm up produces Ischaemic ST segment changes and arrhythmias & reduction of left Ventricular ejection fraction, even In healthy individuals. (BACR, 1995 pg. 84) 14/11/

EXERCISE IN CARDIAC REHABILITATION Exercise, the cornerstone of CR esp. Phase II & III. Prescribe with the same precision as any medication. The ex.

27 EXERCISE IN CARDIAC REHABILITATION Exercise, the cornerstone of CR esp. Phase II & III. Prescribe with the same precision as any medication. The ex. dose is the combination of intensity, frequency and duration of physical activity. Sufficient to produce a conditioning, but not enough to provoke complication. Aimed at enhancing cardiovascular fitness, strength, endurance and flexibility.

28 PATIENT EDUCATION (CRP I & II) One to one home counseling OR Group Education

Physiotherapist/Exercise Physiologist Nurses/ Cardiac Nurse

29 CR EFFECTIVENESS IS DETERMINED BY A MULTIDISCIPLINARY APPROACH Cardiothoracic Surgeon Cardiologist Psychologist Physiotherapist/Exercise Physiologist Nurses/ Cardiac Nurse Dietician Pharmacist Diabetic Counselor Quit Smoking Counselor Patient and family

30 Provide Smoking-cessation Advice And Support To All Patients Who Smoke Smoking is one of the most significant risk factors for cardiovascular disease, including myocardial infarction (MI). Stopping smoking is associated with a substantial reduction in risk of allcause mortality among patients with coronary heart disease. Quitting smoking reduces the likelihood of a repeat cardiac event and the chances of developing other forms of cardiovascular disease. There is a rapid reduction in the risk of coronary heart disease within one year of quitting smoking. Brief educational interventions of 3 5 minutes have been shown to increase quitting rates compared with no intervention.

31 CATEGORY OF CLIENTS: QUIT SMOKING CLINIC IJN Referral case Referred by IJN Doctors ( in patient/outpatient) referral form doctor required cardiac Rehab Nurse will see patient and conduct counselling Self referred Patient call IJN for appointment slot will be given to client will be seen in clinic for counselling New referral - Outpatient / in patient ( We will see on the same day )

32 WHY IS SMOKING HARMFUL TO THE CARDIOVASCULAR SYSTEM? Increased tendency for vasoconstriction Increases level of bad cholesterol ie. LDL Reduces level of good cholesterol ie. HDL Reduces beneficial effects of medications eg. Statins, Aspirin

33 IMMEDIATE BENEFITS OF QUITTING Duration Of Abstinence Bonus 20 mins Lowers blood pressure & heart rate 8-12 hours Carbon monoxide & nicotine levels lowered by 50% 24 hours Oxygen levels normalize & immediate risks of heart attacks 48 hours Sense of smell & taste improves Nicotine disappears from body 2 weeks Circulation improves & lung function increase by 30% 4 weeks Nicotine withdrawal symptoms disappear

34 CONT.. The Right Way of Quitting Fix a date, be confident and look forward Always be positive and get support Fight your urge to smoke or use nicotine replacement therapy Drink lots of water to flush chemical Exercise > 5 minutes (stretching )or exercise Wash faces & keep hand wet Take shower more frequent Do chew gum with sugar free or vitamin C Avoid caffeine drink change to fruit juice Stop thinking about cigarette, divert to other things Distract yourself from situations which encourages smoking Do pray

35 TREATMENT AVAILABLE (PHARMACOLOGIC APPROACH) Non nicotine treatment (Non - NRT) in IJN 1.Champix tablet (varenicline) Nicotine treatment (NRT) buy from other companies 1.Nicorette tablet 2.Nicotine patch 3.Nicotin gum If patient request for NRT, send prescription slip to retail pharmacy, purchase and call patient.

36 CONT.. Choosing the right pharmacologic agent Patient preference Patient s previous experience with medication, either positive or negative Ease of administration Compliance Health care professional s familiarity with medications

37 CONT (Non NRT TAB CHAMPIX VARENICLINE TARTRATE ) Doses : 0.5 mg DLY x 3 /7 0.5 mg BD x 4/7 1.0 mg BD x 11/52 2. Treatment for 12 weeks Am dose - After light breakfast Or 11/2-2 hours after heavy breakfast Pm dose hrs. - 2 hrs. after dinner (To prevent from nausea or vomiting) NRT can take with others medication

38 COMMUNICATE MANAGEMENT PLAN TO THE PATIENT, CARERS AND THE COMMUNITY HEALTHCARE PROVIDERS Effective communication between the hospital, patients and their families/carers, and community healthcare providers enhances long-term adherence with prescribed therapies and lifestyle changes. Include the patient s GP and, as applicable, community pharmacists, community nurses and other outpatient services.

39 Adherence to Therapy Improves Survival Patients discontinuing their medicines after an MI is common, often soon after discharge. Minimise this by: Educating patients about their medicines. This is likely to improve their understanding and knowledge and thus adherence. Starting patients on secondary preventive therapies and lifestyle changes before they leave hospital. This significantly improves long-term adherence. Involving family members in educational efforts. Smoking cessation, weight loss and increased physical activity are enhanced by enlisting the support of family members. Communicating risk of future cardiovascular events.

40 Long-Term Management A discharge letter/summary should include: A complete list of medicines. Document why guideline medicines have not been prescribed and alternative medicine(s) used. Any changes to medicines being taken at admission. A plan for required dose titration (include who is responsible). Recommendations for monitoring and management of medicine-related adverse effects. Treatment goals including blood pressure, blood lipid levels, weight, HbA1c. Referral for cardiac rehabilitation. Advice given on lifestyle modifications (e.g. smoking cessation as applicable). Recommendations for use of dose-administration aids, carer support and referral for a Home Medicines Review.

41 Thank you

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Myocardial infarction: secondary prevention in primary and secondary care for patients following a myocardial infarction 1.1