THE HEART OF THE MATTER MAYANNA LUND CMH

Transcription

1 THE HEART OF THE MATTER MAYANNA LUND CMH

2 CARDIOLOGY ASSESSMENT AND WHEN TO REFER

3 CHEST PAIN - ACUTE History Examination: vital signs are vital ECG Troponin Concerns: MI, unstable angina, PE, aortic dissection

4 Diagnosis?

5 CHEST PAIN - CHRONIC Detailed history critical Underlying heart disease Precipitants, duration, response to therapy Associated symptoms Exam: vital signs, bruits, focal tenderness, murmurs ECG FBC, urea, creatinine, electrolyes, glucose, lipids Refer to cardiology if cardiac pain likely

6 BREATHLESSNESS A non specific symptom and often the cause is multifactorial In heart failure: Most specific symptoms: orthopnoea and PND Most specific signs: elevated JVP and S3 Always consider smoking history and BMI Refer to cardiology if HF likely

7 NT-BNP FOR DIAGNOSIS OF HF IN PRIMARY CARE NT-proBNP level High >220 pmol/l NT-proBNP level Intermediate pmo/l NT-proBNP level Low <50 pmol/l Heart failure Echo Consider noncardiac disease GLs for HF Management (including investigation) Systolic dysfunction Diastolic dysfunction

8 Rule-out and rule-in cut off in the ER Setting NT-proBNP [pmol/l] 212 Acute CHF likely Acute CHF less likely, consider age-stratified cut points Acute CHF unlikely Age [years] Januzzi et al. JACC 2005

9 PALPITATIONS Single episode/occasional extra or dropped beat with no associated symptoms. In general, reassure if the following are normal. Exam ECG Electrolytes, TFTs Recurrent runs of irregular or rapid palpitations As above (ECGs with symptoms are very valuable) Consider referral Beware SVT masquerading as panic attacks

10 Diagnosis?

11 ATRIAL FIBRILLATION Acute onset admit Longer duration Associated symptoms Rate control Stroke risk (there s an app for that) Most patients with AF should have echocardiographic assessment

12 SYNCOPE History is critical Potential cardiac causes: Arrythmia Valve disease Critical ischaemia Neuro and cardiac exam FBC, TFT, urea, electrolytes, creatinine ECG

13 Diagnosis?

14 MURMURS Loudness of murmur severity History duration rheumatic fever associated symptoms, eg. angina, SOB, palpitations or syncope family history ECG +/- CXR

15 CARDIAC EFFECTS OF PSYCHOTROPIC DRUGS ASSESSMENT AND MONITORING

16 PSYCHOTROPIC MEDICATIONS AND SUDDEN CARDIAC DEATH Risk of drugs based on case reports and epidemiological studies A low absolute risk of life threatening arrhythmias may still have important public health consequences Populations at special risk: known cardiac disease, the elderly, treatment with other negatively impacting drugs Clinical decisions must be based on risk vs benefit

17 QT prolongation and Torsade de Pointes QT-prolongation due to dose dependent inhibition of cellular I kr current

18 Measurements of the QT-interval, examples of T-wave morphology, and Torsade de Pointes Søren Fanoe et al. Eur Heart J 2014;35:

19 QT CORRECTION Bazett s formula: QTc = QT / ( RR)

20 Algorithm for reducing risk of cardiac arrhythmia during treatment with psychotropic medications Søren Fanoe et al. Eur Heart J 2014;35:

21 B* PSYCHOTROPIC MEDICATIONS Category Drug Thorough QT study Antipsychotics Haloperidol Pimozide Sertindole Ziprasindone No No No Yes Anticholinergic s Methadone No Søren Fanoe et al. Eur Heart J 2014;35:

22 Two cases of drug-induced QT prolongation Søren Fanoe et al. Eur Heart J 2014;35:

23 Beware concomitant drugs... Potassium and magnesium wasting diuretics CYP3A4 inhibitors Other QT prolonging drugs Non-prescription drugs Combination antipsychotic drug therapy has only been evaluated in RCTs to a very limited extent, and QT effects are unpredictable

24 QT PROLONGING AGENTS IN THE PATIENT AT HIGH RISK FROM THEIR PSYCHIATRIC ILLNESS Assess cardiac risk Optimize cardiac risk factors Choose the drug with the most favourable cardiac risk profile (if possible) Avoid electrolyte disturbances Repeat ECG when drug is at steady state (and after dose increases) In general, if QTc > 500ms, stop the drug

25 Comparative Mortality Risk in Adult Patients Participating in Psychopharmacology Clinical Trials Khan, JAMA Psychiatry. 2013;70(10):

26 CLOZAPINE AND THE HEART

27 CMH guideline Initial monitoring: a. Daily pulse, BP (lying and standing), Temp, bowel motions during titration b. Troponin I or troponin T, CRP weekly for 4 weeks c. ECG at maintenance dose d. Routine ongoing review includes cardiac risk factors such as BMI (monthly), HbA1C (3 monthly), lipids (3 monthly)

28 Cardiac complications Hypotension (alpha-adrenergic antagonist effect) Tachycardia (vagal inhibition, anticholinergic effect, hypotension) Hypertension Myocarditis/Cardiomyopathy Rare and most commonly early after treatment started Referral required In general clozapine treatment should be stopped QTc prolongation

29 If patient develops: Signs or symptoms of unidentified illness OR HR 120bpm or increased by >30bpm OR CRP mg/L OR Mild elevation in Tn ( 2 ULN) Troponin > 2 ULN OR CRP > 100mg/L Continue clozapine with increased monitoring Check Tn and CRP daily Monitor for developing illness Cease clozapine Consult cardiologist Echocardiography

30 LONG TERM CLOZAPINE USE AND LV DYSFUNCTION Clinically severe clozapine induced cardiomyopathy 51.5/100,000 patient years No agreement on routine review with cardiac imaging Chow. Open Heart 2014

31 Compared with healthy controls 2 groups with schizohrenia: BMI Clozapine group smoking rate hypercholesterolaemia resting HR Low HDL and neutrophila were independent predictors of LVD Chow. Open Heart 2014

32 CONTEMPORARY UNDERSTANDING OF CV RISK

33 BASIC CONCEPTS Treat the risk not the risk factor All people with prior CVD events are high risk You cannot calculate CVD risk in your head Managing risk = lifestyle + drugs with proven outcome benefit

34 Physical diseases with increased frequency in severe mental illness De Hert. World Psychiatry 2011;10:52-77

35 Henderson. Lancet Psychiatry 2015:452

36 Putative reasons for excessive and premature CVD among youth with major depressive disorder and bipolar disorder Goldstein et al. Circ. 2015;132:965

37 Relationship between cardiovascular disease and depression Hare. Eur Heart J 2014;35:

38 Relative likelihood of metabolic disturbance with antipsychotics De Hert. World Psychiatry 2011;10:52-77

39 BASELINE CV RISK IS VERY HIGH IN SERIOUS MENTAL ILLNESS.. De Hert. World Psychiatry 2011;10:52-77

40 ..OR THEN AGAIN Foguet-Boreu. BMC Psychiatry 2016;16:141

41 This has only calculated risk of fatal CV event. What about the misery of a non fatal MI or stroke?? A 55 year old smoker with marked hypertension and dyslipidaemia, and the percentage risk doesn t look too bad??

42 SIMPLICITY VERSUS THE TRUTH A NON-EXHAUSTIVE LIST OF RISK FACTORS Age Gender Ethnicity Family history BP BMI Diabetes Waist circumference Lipids Smoking Activity levels hscrp hs Troponin Etc, etc...

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58 THE EFFECT OF BEING GIVEN CV RISK ESTIMATES Usher-Smith. BMJ Open 2015