Clinical Update / Cardiac Clinical Update / Cardiac RehabilitationRehabilitation

Maureen Geens SRN BSc (Hons)

Sponsored by BHF

ObjectivesObjectives

Brief clinical update

Cardiac Rehabilitation

Case Studies

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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)

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

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)

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

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

PLAQUE RUPTURE AND THROMBUS FORMATION

ADP

Platelets

Red blood cell

Fibrinstrands

Smoothmuscle

cells

Fibrouscap

FRESH ATHEROTHROMBOSIS

Vessel wall

Vessel lumen

Thrombus

Red cell-rich regions

Fibrin-richregions

Atheromatousplaque

Acute Coronary SyndromesAcute Coronary Syndromes

BMS DES

… DES are highly effective

Suppression of intimal proliferation

Bare metal stent versus Drug Eluting Stent

Primary PCI pre / postPrimary PCI pre / post

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

Why Cardiac RehabilitationWhy Cardiac Rehabilitation

What can we do?

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.

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

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)

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

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

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

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

Exercise programmeExercise programme

Provided by specialist cardiac physiotherapist and support therapist

Individual assessment

Functional capacity and METs

Individualised programme

Method of deliveryMethod of delivery

Individualised Home based

One to one clinic based

Low /medium risk / supervision group setting

High risk / supervision group setting

Cardiac Service DeliveryCardiac Service Delivery

Home visits

Cardiac nurse clinic

Telephone support

Telehealth monitoring

Heart Manual, angioplasty plan facilitation

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

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

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

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

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

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

Any Questions?