Management of chest pain and heart failure. Cardiac rehabilitation and secondary prevention

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Management of chest pain and heart failure. Cardiac rehabilitation and secondary preventionWT BongDept of Family Medicine, HUKMCase scenario 160 yo gentleman, a known…
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Management of chest pain and heart failure. Cardiac rehabilitation and secondary preventionWT BongDept of Family Medicine, HUKMCase scenario 1
  • 60 yo gentleman, a known case of DM for the past 2 years complains of chest pain for the past 2-3 months when he walks more than 10 minutes. The chest pain radiates to left arm, lasts 5 min, relieved by rest. Currently during his visit to the primary care clinic, he has no chest pain. He is a smoker for the past 40 years. He is on metformin 500mh bd only. Clinically, BP 120/60mmHg and cardiovascular examination was unremarkable.
  • Patient comes in with chest pain..
  • ?cardiovascular
  • Cardiac.
  • MV prolapse.pericarditis
  • ischemic
  • Non cardiac. Aortic dissection
  • ?gastrointestinal. GERD
  • ?Musculoskeletal.fibromyalgia.
  • ?pulmonary
  • ?psychogenic
  • Patient comes in with chest pain..
  • ?cardiovascular
  • Cardiac.
  • MV prolapse.pericarditis
  • ischemic
  • Non cardiac. Aortic dissection
  • ?gastrointestinal. GERD
  • ?Musculoskeletal.fibromyalgia.
  • ?pulmonary
  • ?psychogenic
  • We start with stable angina..
  • By definition. Clinical syndrome characterised by
  • discomfort in chest, jaw, shoulder, back or arm
  • Typically aggravated by exertion or emotional stress
  • Reduced by rest or GTN
  • Most common cause for stable angina is atherosclerotic coronary artery disease (CAD)
  • Other causes could be
  • Hypertrophic cardiomyopathy
  • Aortic stenosis
  • Coronary vasospasm etc
  • Atherosclerosis process in coronaryStable angina is classified into 4 classes based on Canadian Cardiovascular Society Classification (CCS 0-IV)However, it might become unstable, which is unstable angina, with possible progression to NSTEMI and STEMI tooDiagnosis of stable angina can be established by
  • Clinical assessment
  • Look for complication of CAD.murmur(MR).septaldefect.sign of cardiomegaly.CHF
  • Other site of atherosclerosis.carotidbruit.peripheral vascular disease.aortic aneurysm
  • Risk factor for atherosclerosis.hpt.metabolicsyn
  • Other cause of angina.HOCM.aorticstenosis
  • Lab test
  • Specific cardiac investigation
  • Lab test to establish CVS risk factor
  • FLP. FBS. homocysteine level
  • Determine prognosis, creatinine
  • CXR only if suspect CHF if want to see calcification, cardiomegaly/atrial enlargement, valvular disease, pulmonary congestion (help establish prognosis)
  • Specific cardiac investigation
  • Specific cardiac investigation, non invasive
  • ECG. See previous ischemia, LVH, BBB, arrhythmia or conduction defect
  • Stress test. More sensitive and specific than resting ECG
  • Echo.when there is abnormal auscultation suggest valvular, if HCM or prev MI changes on ECG, SSx CHF , to study diastolic function
  • Risk-stratify our patient
  • For the purpose of prognosis + treatment (revascularize in high risk patient)
  • Clinical history – important predictor of adverse outcome in established CADRisk stratify .. Higher risk if ECG showsOther aspects to be considered in risk-stratifying
  • Stress test
  • Ventricular function
  • COROS
  • Treatment goal
  • Prevent MI & death
  • Improve SSx of angina & increase QoL
  • Non pharmacological approachLife styledietVariety of fruits and vegetable.legumes.nuts. Soy products.low fat dairy.whole grainReplace saturated & trans-fat (red meat.whole milk . Pastries) with polysaturated fat (oily fish,walnut,sesame. Pumpkin seed.vegetable oil)Soluble fibre.oat.peas.bean
  • Smoking cessation
  • 36 % risk reduction mortality
  • 32 % risk reduction non fatal MI
  • Nicotine replacement is safe and cost effective even for CAD patient (take into account risk of depression and suicidal thought)
  • educationCan also take GTN as preventive measure if patient know he is going to have attack while carrying out some activityIf SSx persist more than 10min at rest or not improved after 3 tablet of GTN, advice to go to hospital Self managementDuring acute anginal attackRestrain activityGTN S/L or spraySit . Hypotension. Headache after GTNrevascularization
  • PCI or CABG
  • In high risk group it is firstline treatment
  • Significant LMS ( > 50% stenosis)
  • Significant proximal mutivessel involvement
  • Multivessel disease with impaired LV function with proven viable myocardium
  • Or if failed medical treatment to control angina SSx
  • In asymptomatic patient, consider if there is extensive inducible ischaemia (stress test)
  • What if it is aMI ?Secondary prevention
  • Basically similar to angina which include
  • Oral Anticoagulant (warfarin)
  • If AF
  • LV thrombus for 3-6mths
  • Secondary prevention
  • Hormone replacement therapy is not beneficial for secondary prevention
  • Postmenopausal women who were taking HRT at the time of STEMI should discontinue it
  • Vitamin E and antioxidants have no clinical benefit
  • Garlic, lecithin, vitamin A and C are not beneficial
  • Heart failureHeart failure
  • Is a complex clinical syndrome results from structural or functional impairment of ventricular filling or ejection of blood
  • Cardinal manifestation are dyspnea, fatigue, which may limit effort tolerance, and fluid retention, which may lead to pulmonary or splanchnic congestion or peripheral edema.
  • Definition of Heart FailureStages, Phenotypes and Treatment of HFClassification of Heart FailurePhysical examination
  • BMI and evidence of weight loss
  • Bp, supine and upright( orthostatic changes – volume depletion)
  • Pulse – strength and regularity
  • JVP
  • Extra heart sound, murmur, apex beat displacement, RV heave
  • Pulmonary status
  • Hepatomegaly
  • Peripheral edema
  • Lab investigation
  • Class I
  • 1.Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C)
  • 2.Serial monitoring, when indicated, should include serum electrolytes and renal function. (Level of Evidence: C)
  • 3.A 12-lead ECG should be performed initially on all patients presenting with HF. (Level of Evidence: C)
  • Class Iia
  • 1.Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF (Level of Evidence: C)
  • 2.Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)
  • Recommendations for Biomarkers in HFRecommendations for Noninvasive ImagingACC AHA heart failure 2013
  • Treament based on stages of heart failure
  • ACC AHA heart failure 2013
  • Stage A: Recommendations
  • Class I
  • 1.Hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of HF(Level of Evidence: A)
  • 2.Other conditions that may lead to or contribute to HF, such as obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided. (Level of Evidence: C)
  • HFSA 2010 Practice Guideline (3.1)Heart Failure PreventionAdapted from:HFSA 2010 Practice Guideline (3.2)HF Risk Factor Treatment GoalsAdapted from:Treating Hypertension to Prevent HFAggressive blood pressure control:Aggressive BP control in patients with prior MI:Decreasesrisk of new HFby ~ 50%56% in T2DMDecreasesrisk of new HFby ~ 80%Lancet 1991;338:1281-5 (STOP-HypertensionJAMA 1997;278:212-6 (SHEP)UKPDS Group. UKPDS 38. BMJ 1998;317:703-713HFSA 2010 Practice Guideline (3.3-3.4)Prevention—ACEI and Beta BlockersACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:
  • Coronary artery disease
  • Peripheral vascular disease
  • Stroke
  • Diabetes and another major risk factorStrength of Evidence = A
  • ACE inhibitors and beta blockers are recommended for all patients with prior MI.Strength of Evidence = AHFSA 2010 Practice Guideline (4.8, 4.10)Heart Failure Patient EvaluationRecommended evaluation for patients with a diagnosis of HF:
  • Assess clinical severity and functional limitation by history, physical examination, and determination of functional class*
  • Assess cardiac structure and function
  • Determine the etiology of HF
  • Evaluate for coronary disease and myocardial ischemia
  • Evaluate the risk of life threatening arrhythmia
  • Identify any exacerbating factors for HF
  • Identify co-morbidities which influence therapy
  • Identify barriers to adherence and complianceStrength of Evidence = C
  • *Metrics to consider include the 6-minute walk test and NYHA functional classAdapted from:Recommendations for Treatment of Stage B HFTreatment of Stages A to DStage CTreatment of Stages A to DNonpharmacological InterventionsIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIStage C: Nonpharmacological InterventionsPatients with HF should receive specific education to facilitate HF self-care.Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status. Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms. ABTreatment of Stages A to DPharmacological Treatment for Stage C HFrEFPharmacologic Treatment for Stage C HFrEFIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIPharmacological Treatment for Stage C HFrEF (cont.)Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms.ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality.ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.AADrugs Commonly Used for HFrEF (Stage C HF)Drugs Commonly Used for HFrEF (Stage C HF) (cont.)IIIaIIbIIIPharmacological Treatment for Stage C HFrEF (cont.)ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications, unless contraindicated.Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated.IIIaIIbIIIAAIIIIaIIaIIbIIbIIIIIIPharmacological Treatment for Stage C HFrEF (cont.)Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFrEF. Use of 1 of the 3 beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality.AHarmIIIaIIbIIIPharmacological Treatment for Stage C HFrEF (cont.)Aldosterone receptor antagonists [or mineralocorticoid receptor antagonists (MRA)] are recommended in patients with NYHA class II-IV and who have LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists.AIIIIaIIaIIbIIbIIIIIIPharmacological Treatment for Stage C HFrEF (cont.)Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of 40% or less who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine greater than 2.5 mg/dL in men or greater than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73m2), and/or potassium above 5.0 mEq/L.BHarmBIIIIaIIaIIbIIbIIIIIIPharmacological Treatment for Stage C HFrEF (cont.)The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients self-described as African Americans with NYHA class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated.A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.ABIIIIaIIaIIbIIbIIIIIIPharmacological Treatment for Stage C HFrEF (cont.)Digoxin can be beneficial in patients with HFrEF, unless contraindicated, to decrease hospitalizations for HF.Patients with chronic HF with permanent/persistent/ paroxysmal AF and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ≥75 years of age) should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation).ABIIIIaIIaIIbIIbIIIIIIPharmacological Treatment for Stage C HFpEF (cont.)Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF.The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF. Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTsTreatment of Stages A to DTreatment for Stage C HFpEFTreatment of HFpEFTreatment of Stages A to DDevice Treatment for Stage C HFrEFIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIDevice Therapy for Stage C HFrEF ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease at least 40 days post-MI with LVEF of 35% or less, and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival for more than 1 year.CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms or greater, and NYHA class II, III, or ambulatory IV symptoms on GDMT. AABNYHA Class III/IVNYHA Class IITreatment of Stages A to DStage DClinical Events and Findings Useful for Identifying Patients With Advanced HFAdapted from Russell et al. Congest Heart Fail. 2008;14:316-21.Treatment of Stages A to DWater RestrictionIIIaIIbIIIWater RestrictionFluid restriction (1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms.IIIIaIIaIIbIIbIIIIIISurgical/Percutaneous/Transcatheter Interventional Treatment of HFCoronary artery revascularization via CABG or percutaneous intervention is indicated for patients (HFpEF and HFrEF) on GDMT with angina and suitable coronary anatomy, especially for a left main stenosis (>50%) or left main equivalent disease.CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction (EF 35% to 50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis when viable myocardium is present in the region of intended revascularization.BHeart failure with preserved EF or diastolic heart failureHeart failure with preserved EFCase scenario 2
  • A 55 yo man presents with gradually increasing shortness of breath and leg swelling that occurred while on a business trip. He has congestive heart failure, which has caused fatigue and shortness of breath if he walks a block or climbs a flight of stairs. BP is 140/ 90; there is no jugular venous distension or gallop, and only minimal pedal edema. AN echo shows left ventricular EF 45 %. Current medication include aspirin and simvastatin. The patient desires to keep medications to a minimum. What additional treatments are indicated at this time?
  • A. Spironolactone
  • B. ACE inhibitor and beta blocker
  • C. Digoxin
  • D. Frusemide
  • E. An implantable defibrillator
  • Cardiac rehabilitation
  • Coordinated interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing or slowing the progress of underlying atherosclerotic process, thereby reducing morbidity and mortality.
  • Answer is B
  • ACE inhibitor is recommended in both symptomatic n asymptomatic heart failure
  • Beta blocker stabilize left ventricular remodeling
  • Spironolactone recommended for NYHA III-IV with EF <35% despite on loop diuretic + ACEi + b blocker
  • Frusemide can improve SSx but patient wants to keep medication to minimal
  • Defibrillator not indicated yet
  • Cardiac rehabilitation
  • Include
  • baseline patient assesssment,
  • nutritional counselling,
  • aggressive risk factor management ie
  • lipid, hpt, weight, diabetes and smoking,
  • psychosocial and vocational counseling , and
  • physical activity counseling and exercise training, in addition to
  • appropriate use of cardioprotective drugs that have evidence-based efficacy for secondary prevention
  • Who should be included in cardiac rehab ?
  • Patient with previous MI
  • Who had undergone CABG
  • Those with PCI done
  • Heart transplant candidate or recipient
  • Who has stable chronic heart failure, peripheral arterial disease
  • Exercise training interventionReturn to workCardioprotective mechanism (improve endothelial function)Risk factor modification & interventionAggresive reduction of risk factors via nutritional counselling, weight management, adherence to drug therapyPsychosocial intervention (address depression, anxiety, social isolation. Consider SSRI, cognitive behavioral therapy.Thank you for your kind attention
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