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

1. Management of chest pain and heart failure. Cardiac rehabilitation and secondary prevention WT Bong Dept of Family Medicine, HUKM

2. Case 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.

3. Patient comes in with chest pain.. • ?cardiovascular • Cardiac. • MV prolapse.pericarditis • ischemic • Non cardiac. Aortic dissection • ?gastrointestinal. GERD • ?Musculoskeletal.fibromyalgia. • ?pulmonary • ?psychogenic

4. Patient comes in with chest pain.. • ?cardiovascular • Cardiac. • MV prolapse.pericarditis • ischemic • Non cardiac. Aortic dissection • ?gastrointestinal. GERD • ?Musculoskeletal.fibromyalgia. • ?pulmonary • ?psychogenic

5. 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

6. Most common cause for stable angina is atherosclerotic coronary artery disease (CAD) • Other causes could be • Hypertrophic cardiomyopathy • Aortic stenosis • Coronary vasospasm etc

7. Atherosclerosis process in coronary

8. Stable angina is classified into 4 classes based on Canadian Cardiovascular Society Classification (CCS 0-IV)

9. However, it might become unstable, which is unstable angina, with possible progression to NSTEMI and STEMI too

10. Diagnosis 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

11. 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

12. 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

13. Risk-stratify our patient • For the purpose of prognosis + treatment (revascularize in high risk patient)

14. Clinical history – important predictor of adverse outcome in established CAD

15. Risk stratify .. Higher risk if ECG shows

16. Other aspects to be considered in risk-stratifying • Stress test • Ventricular function • COROS

17. Treatment goal • Prevent MI & death • Improve SSx of angina & increase QoL

18. Non pharmacological approach Life style diet Variety of fruits and vegetable.legumes.nuts. Soy products.low fat dairy.whole grain Replace 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)

20. education Can also take GTN as preventive measure if patient know he is going to have attack while carrying out some activity If SSx persist more than 10min at rest or not improved after 3 tablet of GTN, advice to go to hospital Self management During acute anginal attack Restrain activity GTN S/L or spray Sit . Hypotension. Headache after GTN

24. revascularization • 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)

25. What if it is aMI ?

27. Secondary prevention • Basically similar to angina which include

28. Oral Anticoagulant (warfarin) • If AF • LV thrombus for 3-6mths

29. 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

30. Heart failure

31. Heart 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.

32. Definition of Heart Failure

33. Stages, Phenotypes and Treatment of HF

34. Classification of Heart Failure

35. Physical 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

36. 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)

37. Recommendations for Biomarkers in HF

38. Recommendations for Noninvasive Imaging

39. ACC AHA heart failure 2013 • Treament based on stages of heart failure

41. 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)

42. HFSA 2010 Practice Guideline (3.1)Heart Failure Prevention Adapted from:

43. HFSA 2010 Practice Guideline (3.2)HF Risk Factor Treatment Goals Adapted from:

44. Treating Hypertension to Prevent HF Aggressive blood pressure control: Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 50% 56% in T2DM Decreases risk of new HF by ~ 80% Lancet 1991;338:1281-5 (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:703-713

45. HFSA 2010 Practice Guideline (3.3-3.4)Prevention—ACEI and Beta Blockers ACE 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 = A

46. HFSA 2010 Practice Guideline (4.8, 4.10)Heart Failure Patient Evaluation Recommended 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 class Adapted from:

47. Recommendations for Treatment of Stage B HF

48. Treatment of Stages A to D Stage C

49. Treatment of Stages A to D Nonpharmacological Interventions

50. I I I IIa IIa IIa IIb IIb IIb III III III Stage C: Nonpharmacological Interventions Patients 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. A B