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Chronic Medical Conditions

Chronic Medical Conditions. Liz Borlase Brampton Medical Practice. Chronic medical conditions. QOF and other chronic conditions Designing protocols – two groups Cardiovascular cases – pairs Challenges of multiple morbidity. Chronic medical conditions. Make a quick list….. or two!.

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Chronic Medical Conditions

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  1. Chronic Medical Conditions Liz Borlase Brampton Medical Practice

  2. Chronic medical conditions • QOF and other chronic conditions • Designing protocols – two groups • Cardiovascular cases – pairs • Challenges of multiple morbidity

  3. Chronic medical conditions • Make a quick list….. or two!

  4. Atrial fibrillation CHD HF Hypertension PAD Stroke/TIA DM Hypothyroid Asthma COPD Dementia Depression Mental Health Cancer CKD Epilepsy Learning Disability Osteoporosis Rheumatoid arthritis Palliative care QOF Clinical Indicators

  5. Addisons Coeliac disease HIV / AIDS Hyperthyroid Inflammatory bowel disease Irritable bowel syndrome Migraine Multiple sclerosis Osteoarthritis Parkinsons disease Polymyalgia Psoriasis …………etc. Other chronic medical conditions

  6. Designing protocols • M72 with letter from cardiology confirming new HF on echocardiogram, no other PMH • DH: furosemide 40mg daily, aspirin 75mg daily, and simvastatin 40mg nocte • Letter advises titrating ramipril and bisoprolol • How is this to be organised within the PHCT? • What? When? By whom? • How will you check it is completed?

  7. Heart failure - management • Manage other conditions eg BP • Diuretics if needed • Lifestyle etc • ACE inhibitor or ARB • Beta blocker • Spironolactone • Add ARB • ?hydralazine & nitrates, pacing, digoxin

  8. Heart failure - management • Refer for: • Diagnosis • Severe heart failure not responding to treatment • Valve disease • Pre-pregnancy or pregnant

  9. Heart failure - management • Seattle heart failure model • http://depts.washington.edu/shfm/app.php

  10. Designing protocols • Pick another chronic disease from our list (not QOF) • Design a brief protocol for their follow up • What? When? Where? How? By whom?

  11. Tea break

  12. Cardiovascular • Chest pain • Palpitations • Breathlessness • Ankle swelling • Dizziness/faints

  13. Cardiovascular • Cases…..

  14. Case 1 • F74 3/52 SOBOE • Feels her heart thumping • PMH - BP, THR, DM, TIA • furosemide, amlodipine, alendronate and Adcal D3 • Irreg pulse • ECG AF HR110

  15. Investigations for AF • CVD risk - U&E, eGFR, LFT, Ca, TFT, Chol, HbA1C, FBC • Echo – younger patients, planning for cardioversion, HF, murmur • NOT routinely

  16. Rate control • Over 65 • With IHD • Contraindications to antiarrhythmic drugs • Unsuitable for cardioversion • C.I. to anticoagulation • Large atrium, M.S. • AF > 12 months • Multiple failed attempts • Reversible causes e.g. thyrotoxicosis

  17. Rate control • Beta- blocker or rate-limiting calcium antagonist • Add digoxin if needed • Target resting HR < 90 • Target exercise HR < 200 minus age

  18. Rhythm control • Symptomatic • Younger • Presenting first time, lone AF • Secondary to corrected precipitant • CHF

  19. Stroke prevention • CHADS2

  20. CHADS2 Scoring Scheme

  21. CHADS2 Scoring Scheme

  22. CHA2DS2-VASc Scoring

  23. Patient Decision Aids • National Prescribing Centre (provided by NICE) • http://www.npc.nhs.uk/patient_decision_aids/pda.php

  24. Starting warfarin for AF • INR target 2.5 • No loading dose • Yellow book • Phone number • Patient information including diet • Records • Safety systems • INRstar

  25. Case 2 • F42 nurse • 3/12 intermittent palpitations • Slight dizziness • Similar 10y ago on nights • PMH – anxiety, depression • FH – thyroid disease, DM • No current medication

  26. Palpitations - causes • Stress, anxiety • Menopause • Hyperthyroid • Anaemia • Caffeine, alcohol • Medication • Chronic fatigue • Hypoglycaemia

  27. Palpitations - questions • Precipitating/relieving factors • Regular/irregular • Pulse • Lifestyle • Current stress/mood • Weight change • Periods

  28. Palpitations - investigations • Bloods • ECG • 24h tape • Event recorder

  29. Case 3 • M56 chest pain the day before • After food • Sweating • 20 minutes • Chest exam normal, BP 155/95 • ECG normal

  30. Chest pain - ?ACS • History of pain • > 15 mins • N&V, sweating, SOB • Cardiac unlikely if • Continuous • Unrelated to activity • Brought on by breathing • Associated dizziness, palpitations, tingling, swallowing sx • Cardiovascular risk factors • Previous IHD • Previous investigations

  31. Chest pain – ACS • CURRENT PAIN, OR PAIN WITHIN 12h & ECG CHANGES • 999 Ambulance • GTN, opioids • Aspirin • ECG • Pulse oximetry, oxygen only if sats <94% or if COPD <88%

  32. Chest pain – ACS • PAIN WITHIN 12h & NORMAL ECG, OR PAIN 12 – 72h • Urgent same-day hospital assessment • PAIN > 72h • History, exam, ECG, troponin • Then decide….

  33. Stable chest pain • Confirmed IHD - treat or if uncertain Ix • Typical angina - ECG, bloods, aspirin, treat • Atypical angina – ECG, bloods, refer for Ix • Non-anginal chest pain – consider GI and MSK

  34. Stable angina • GTN spray • Aspirin, statin, BP, ACE I if DM • Beta-blocker or calcium channel blocker • Alternatives: long acting nitrates, ivabradrine, nicorandil

  35. Multiple morbidity • What are the challenges? • Any ideas for addressing these challenges?

  36. Thank-you! Evaluation forms please….

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