Reducing the risk of CHD

Jane Dudley

Heart Failure Specialist Nurse

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Cardiovascular Disease – a Public Health Issue

Diseases of the heart and circulatory system are called cardiovascular diseases or CVD.

CVD are the main cause of death in the UK - approximately 198,000 deaths a year( BHF 2006)

Main forms of CVD are coronary heart disease (CHD) and stroke.

Approximately 48% of all deaths from CVD are from CHD; approximately 28% are from stroke.

CHD is the most common cause of death in the UK – 1 in 5 men and 1 in 7 women die from the disease.

94,000 deaths in the UK are from CHD ( BHF 2006)

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Health inequalities Death rates from CHD are highest in

Scotland and the North of England, lowest in the South of England.(BHF 2006)

Estimated that every year 5,000 lives and 47,000 working years are lost in men aged 20 to 64 years due to social class inequalities in CHD death rates.

In England and Wales evidence of strong links between deaths from cardiovascular disease and levels of deprivation.

To reduce socio- economic inequalities CVD inequalities targets have been introduced in England, Scotland and Wales(BHF 2006)

Latest evidence suggests that progress towards the CVD indicators is steady but if it continues the inequalities gap should be reduced by 2010.

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Cardiac Markers

Cardiac markers are cardiac enzymes and cell contents.

The measurements of Troponin I and T are of equal clinical values (SIGN 2007)

Optimum time to measure troponin for diagnosis or prognostic risk is 12 hours from the onset of symptoms (SIGN 2007)

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Cardiac Markers Continued

STEMI: Elevated cardiac markers, which indicate necrosis in the heart muscle (plus ST elevation on ECG)

NSTEMI: Elevated cardiac markers which indicate necrosis in the heart muscle (no ST elevation on ECG).

Unstable Angina: No elevated cardiac markers, no necrosis of heart muscle (no ST elevation on ECG)

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ST Elevation

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Definitions

ACS: Acute Coronary Syndrome. • Refers to a range of acute myocardial

ischaemic states. Encompasses Unstable Angina, NSTEMI and STEMI

Unstable Angina• Ischaemia caused by obstruction of a

coronary artery due to plaque rupture with thrombosis and spasm

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Definitions continued

NSTEMI: Non ST segment elevation myocardial infarction

STEMI: ST segment elevation myocardial infarcton

Unstable Angina and NSTEMI account for approximately 2.5 million hospital admissions worldwide

25% of admissions of chest pain (not necessarily cardiac in origin)

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CHD kills 110,000 people 1.4 million people suffer with angina 275,000 suffer a heart attack Each year

Coronary Heart Disease

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Smoking Cessation

70% of smokers under 65yrs want to stop. 43% of smokers over 65yrs want to stop. Main drivers are health and financial. Awareness of the dangers of passive smoking

seemed to have an affect on motivation. Smokers who have support with cessation are

most likely to succeed. NRT doubles the chances of successful

cessation.

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Physical Activity

Physical activity reduces the risk of chd The physically inactive have twice the risk of

developing chd 3% of all disease and 24% of chd can be

attributed to physical inactivity Aerobic activity provides most benefit 30 mins of moderate exercise 5 times a week

is optimum

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Hypertension Direct link between chd and BP. Each rise in BP by 20mmgh systolic and

10mmgh diastolic will double chd mortality risk.

11% of all disease, 50% of CHD and 22% of heart attacks attributed to hypertension.

Optimum: 120/80mmgh. Treatment should be commenced at BP over

140/90mmgh or 135/85mmgh in diabetics.

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Alcohol

High alcohol intake accounts for 9% of all disease and 2% of chd

Is beneficial in small quantities Women 2-3 units per day Men 2-4 units per day Binge drinking increases the risk of chd

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Psychosocial Well Being

Work stress Lack of social support Anxiety and depression Personality traits such as hostility

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Healthy Eating and Obesity

30% of CHD deaths are caused by an unhealthy diet

4% of disease and 30% of CHD is due to poor consumption of fruit and vegetables

Abdominal fat distribution is an indicator of greatest CHD risk in the obese

7% of disease, 1/3 of CHD, 60% of hypertension and 63% of heart attacks are caused by obesity

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General Weight Loss Advise

Every kg of excess weight contains 7500 Kcals, a reduction of 1000 cals per day will lead to 1kg weight loss per week

Food diaries to look at:

Meal patterns Likes and dislikes Hard to resist foods Portion sizes Work and home

arrangements for cooking and eating

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Portion sizes: 3 tbls breakfast

cereal 2 heaped tbls rice 2 egg sized

potatoes

Carbohydrates, proteins, fruit and vegetables all create a feeling of fullness.

High fat and sugary foods should be avoided but an occasional treat will not jeopardise months of dieting.

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Eating for a Healthy Heart

5 portions of fruit and vegetables a day Reduce saturated fat and replace with poly or

mono unsaturated fats Oily fish once a week No more than 6 grams of salt a day High fibre to reduce absorption of dietary

cholesterol

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What is cholesterol? Fatty substance

produced by the liver

Also found in some foods

Cholesterol is released when saturated fat is digested

Cholesterol is carried around the body by LDL, HDL and triglicerides

LDL cholesterol contributes to the development of atheroma

HDL cholesterol transports cholesterol out of the body

Optimum is to have high HDL and low LDL

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Cholesterol and CHD

Direct link between cholesterol and CHD Raised cholesterol accounts for 8% of all

disease and 60% of CHD 45% of heart attacks are caused by raised

cholesterol Recommended level- 4-5 with a HDL

greater than 1

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Reducing cholesterol

Reduce saturated fat intake Statins (simvastatin) reduce cholesterol and

provide overall reduction in CHD risk All patients who have had a heart attack,

have angina or have a cholesterol greater than 5 should be on a statin unless contra indicated

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SMOKING

Ten million smokers in England 20% of CHD deaths in men and 17% in

women are attributed to smoking Smoking cessation reduces risk of CHD by

50% in the first year, followed by a gradual decline to that of a non smoker

Smoking cessation following a heart attack reduces the risk of further heart attack by 24-29%

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Diabetes Type 1 diabetics do not produce any insulin. Type II diabetics have a relative lack of insulin

due to resistance. Men with type II diabetes have 2-4 fold risk of

developing chd and women a 3-5 fold risk compared to non diabetics.

Diabetes increases the risk of heart attack by 3 fold.

Type II diabetes magnifies other risk factors and those with type II diabetes are more likely to have other risk factors.

15% of heart attacks are caused by diabetes.

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ConclusionCHD is: Hereditary More likely to develop with increasing age Is more prevalent in the male population

HOWEVERFor a large proportion of people it is

PREVENTABLE Simple changes can have significant results Health care assistants can assist with the

governments drive to reduce CHD in the UK

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References Department of Health (2000)

National Service Framework for Coronary Heart Disease

Hinchliffe S, Montague S, Watson R (2000)

Physiology for Nursing Practice

www.bhf.org.uk

www.heartstats.org

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Heart Failure - a definition

Heart failure is a complex syndrome

that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. (NICE 2010)

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Echocardiogram

An echocardiogram is a non invasive investigation to look at the atria and ventricles in the heart and assesses for any pathological changes that may be affecting the function of the heart. It also provides an ejection fraction figure which refers to the percentage of blood pumped out from the left ventricle. The procedure can be done as an outpatient or through the Community Echocardiogram service.

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■ It is estimated that over 5% of all deaths in the UK are due to heart failure.

■ People with heart failure have a lower quality of life than people with arthritis, chronic lung disease or angina.

■ In England 2% of all inpatient bed days are due to heart failure. This is projected to increase by 50% over the next 25 years.

■ Annual cost of heart failure to the National Health Service in the UK is about £625

million

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The Health Service cost of Heart Failure

Drugs9%

Outpatient investigations6%

Primary Care17% Inpatient care

60%

OPD care8%

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Aims

Bridge the gap between primary and secondary care

Patient and carer focused To optimise the management and improve

the quality of life experienced Prevent unnecessary hospitalisations Patient journey as smooth as possible and not

fragmented Proactive intervention rather than reactive

response.

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Aims of the Community Heart Failure Nurse

To offer interventions appropriate to the patients needs, incorporating psychosocial and educational input and a review of their medical condition/treatment.

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Causes of Heart Failure

Coronary heart disease/ischaemia Hypertension Heart valve disease Arrhythmias Thyroid Dysfunction Chronic Anaemia Cardiomyopathy – alcoholic, drug

induced,congential, ichaemia.

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New York Heart Association Classification

NYHA class 1 – Symptoms do not occur during normal activity

NYHA class 2 – Symptoms slightly limit normal activity

NYHA class 3 – Marked limitation of normal activities without symptoms at rest

NYHA class 4 – Unable to undertake any physical activity without symptoms. Symptoms at Rest.

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Most sensitive symptom of heart failure Pulmonary oedema (fluid on the lungs) –

back pressure on the lungs from an overloaded left atrium.

Overdrive of the breathing muscles Weakness of breathing muscles

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Signs and Symptoms of Heart Failure

Fatigue/tiredness Breathlessness Peripheral oedema Disturbed sleep( nocturnal cough;

breathlessness) Difficult in concentrating ( hypoxia;

lethargy) Depression (anxiety; poor prognosis) Impaired appetite

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Assessment of fluid status

Daily weights○ 1kg weight gain = 1 litre fluid

Look for oedema (usually evident when 5 litres of fluid is retained) ○ Feet / ankles○ Calves○ Thighs○ Abdominal ascites○ Sacral○ Pitting?

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Fluid Retention / Oedema

Heart failure causes back pressure on the circulation.

Increased venous pressure causes fluid build up in other tissues e.g. lungs, peripheries, abdomen.

Reduced cardiac output leads to reduced blood flow to kidneys which results in sodium and water retention.

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Leg Oedema

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Tiredness / Fatigue

Fatigue is almost always present in heart failure.

Skeletal muscle changes Effortful breathing Poor sleep quality Reduced oxygen in the blood Reduced ability to respond to exertion

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Assessment of tiredness / fatigue

Changes in exercise / activity tolerance Activities of daily living Muscle weakness Pain

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Day to day management

Review of daily weights – action if weight has increased over the last 3 days by 2-4 kgs (4-8lbs).

Fluid restriction if necessary (1.5-2litres) Symptom review Blood pressure (sitting and standing) Heart rate and regularity

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Day to day management

Medication Review Optimisation of medication Education and support Self management End of life choices and care Lifestyle advice – diet, exercise, smoking,

etc

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Other therapy

Coronary Revascularisation Valve Replacement Implantable defibrillators Biventricular pacing Left Ventricular Assist Devices (LVAD) Cardiac Transplantation Gene and cell therapy