Clinical Update / Cardiac Rehabilitation

1. Clinical Update / Cardiac Rehabilitation Maureen Geens SRN BSc (Hons) Sponsored by BHF

2. Objectives Brief clinical update Cardiac Rehabilitation Case Studies

3. Trends in Acute Coronary Syndrome (ACS) 180 160 140 120 100 80 60 40 20 0 1990–1991 1993–1995 1997 1975–1978 1981–1984 1986–1988 Incidence rate (per 100,000) Q-wave Non Q-wave Reprinted with permission: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80

4. Classification of ACS ACS ECG • ST Elevation No ST Elevation Troponin . Aborted MI STE/ACS Myonecrosis not confirmed Myonecrosis confirmed TnT+ve -ve ACS U A 15-49 < 15 STEMI NSTEMI TnT > 50

5. NSTEMI 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)

6. Cardiac 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

7. STEMI 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

10. Acute Coronary Syndromes

11. Suppression of intimal proliferationBare metal stent versus Drug Eluting Stent BMS DES … DES are highly effective

12. Primary PCI pre / post

13. Drug 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

14. Why Cardiac Rehabilitation What can we do?

15. Definition of Cardiac Rehabilitation “ 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.

16. Definition of Cardiac Rehabilitation “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

17. National Service Framework (CHD), (DOH 2000). BACR (2007) Strategic Commissioning Development Unit (SCDU 2010) Local Cardiac Service Review (2010/11) National / Local guidelines

18. Patients post Acute myocardial infarction +/- PPCI or PCI Patients post CABG and Valve surgery Patients following other cardiac surgery on individual basis Elective or emergency PCI patients Patients with ICD Patients with diagnosis of left ventricular systolic dysfunction Patients referred to our service

19. History Clinical assessment Risk factor assessment Lifestyle advice Medication review and optimising therapy Quality of life and Hospital and Anxiety Depression (HAD) scoring Service offers an individualised assessment to include:

20. Service offers an Individualised assessment to include Social and vocational status Exercise programme An agreed individualised care management plan Ongoing clinical assessment, monitoring and support Education facilitation of self management Pro active monitoring and early intervention Psychological support

21. 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 Atrial Fibrillation and stroke risk reduction

22. Provided by specialist cardiac physiotherapist and support therapist Individual assessment Functional capacity and METs Individualised programme Exercise programme

23. Individualised Home based One to one clinic based Low /medium risk / supervision group setting High risk / supervision group setting Method of delivery

24. Home visits Cardiac nurse clinic Telephone support Telehealth monitoring Heart Manual, angioplasty plan facilitation Cardiac Service Delivery

25. Directly with GP if there is a clinical concern – telephone / email Correspondence with letters / email – dependent on preferred route Attending MDTs Liaising with practice nurses as necessary Direct communication with consultants as necessary Direct links in to acute trust & departments Communication and liaising with all members of the multidisciplinary team to optimise patient care and management Communication

26. 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 Audit

27. 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 Professional / clinical support

30. Case 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

31. Case 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

33. Smoking 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

34. Any Questions?