Tag Archives: heart disease

Translation of PQRST wave

  • P wave shows atrial depolarisation as the atria contract
  • QRS complex shows ventricular depolarisation as the ventricles contract and electrical impulse is conducted from the sinoatrial node, down the bundle of His, into the right and left bundle branches and Purkinje fibres.
  • T wave is the repolarisation of the ventricles as the ventricles relax.

Post-MI Care in Primary Care

Patients with a history of myocardial infarction will need appropriate follow-up in primary care to manage risk factors as far as possible, provide patient education and ensure patients are on correct medication.

Patient education to reduce risks of further MIs is important. In particular, patients should be advised to increase their fruit and vegetable intake to at least 5 portions daily, reducing salt and fat intake, adopting a Mediterranean-style diet including consumption of oily fish. Additional supplements of beta carotene, vitamin C or E are not connected with improving outcomes and reducing cardiac risks. NICE guidelines recommend post-MI patients to consume at least 7g of omega-3 fatty acids per week (2-4 portions of oil fish). For patients unable to achieve this, 1g daily omega-3 ester (Omacor) can be prescribed for up to four years for patients who have had an MI in the previous 3 months. Patients should also be advised to reduce their alcohol consumption to low-moderate levels (less than 21 units per week for men and 14 for women).

Obesity needs to be monitored and managed, as this will not only reduce lipid levels as well as blood pressure but also other conditions such as diabetes.

Smoking cessation help should be offered if appropriate. Nicotine replacement therapy is not advised immediately after an MI, but in the long-term continuing to smoke is a serious risk factor.

All post-MI patients should be offered cardiac rehabilitation with an emphasis on exercise. NICE guidelines recommend moderate exercise for 20-30 minutes (enough to feel lightly breathless) five times per week. Brisk walking is ideal. Sexual activity poses no more risk of a further MI, than in a person who had not had an MI. Although when treating erectile dysfunction it is important to remember that PDE5 (phosphodiesterase 5) inhibitors should be avoided in patients using nicorandil, but can be considered in stable patients six months post-MI.

The optimum lipid target is a total cholesterol of <4mmol/l, LDL cholesterol of <2mmol.

A brief anxiety and depression assessment may be required – referring on to mental health services if necessary.

Air travel can be considered three weeks post-MI, and although the DVLA need not necessarily be notified, it is inadvisable to drive in the four weeks immediately post-MI.

Optimum prescribing for post-MI patients includes:

Daily aspirin (proven to reduce death rate by 25%). This is a lifelong treatment and is a first-line drug. Clopidogrel may be prescribed instead of aspirin if a patient has a well-documented hyper-sensitivity. Clopidogrel may be prescribed alongside aspirin for 12 months in patients with non-ST segment elevation acute coronary syndrome.

ACE inhibitors (particularly in patients with left ventricular dysfunction or heart failure), although current NICE guidelines recommend all patients post-MI should be prescribed ACE inhibitors, after checking renal function. If the patient develops a severe cough or oedema, this would need to be reassessed.

Beta-blockers are responsible for a reduction in mortality of up to 25%. New patients may need to be informed that beta blockers can cause lethargy, but this should resolve after a few weeks.

Statins help reduce lipid levels, and it has been found that after five years’ use they prevent further cardiovascular events in 10% of patients. Statins can be started after liver function and CK has been measured to determine the patient’s baseline, although raised liver enzymes should not necessarily rule out the patient from statin therapy. A statin may be augmented by ezetimibe to reduce LDL and total cholesterol.

A low HDL cholesterol (<1mmol/l) is of particular risk to patient with type II diabetes. Fibrates are effective at raising HDL cholesterol.

Particular attention needs to be paid to the patient’s blood pressure – for post-MI patients the target is <130/80mmHg. To achieve this the beta blocker dose may need to be increased or the patient may also require a diuretic or calcium channel blocker.

UK Guidance on Diet could save around 33,000 Lives annually

A study has found if people adhered to the recommended 5 portions of fruit and vegetables each day and reduced their daily intake of salt to 3.5g as well as their saturated fat intake to 3% of their daily energy intake, this could prevent around 33,000 deaths each year. It was calculated that 20,800 coronoary artery disease deaths, 5,876 stroke deaths, amd 6,481 cancer deaths could be prevented each year by following such guidance. Around 12,500 deaths would be in the 75 years and under category.

Scarborough P et al (2010) Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality Journal of Epidemiology and Community Health. Doi:10.1136/jech.2010.114520

Solar UV and Cardiovascular Disease in Women

A study has found that women who had exposure to solar UV light were at reduced risk of developing cardiovascular disease. The study also found that exposure to non-solar UV light increased a woman’s overall risk of dying from cancer.

Yang, L. et al. (2011) Ultraviolet exposure and mortality among women in Sweden. Cancer Epidemiology, Biomarkers and Prevention. 20, 4, 683-690.

Early Menopause

This is menopause experienced before the age of 45. These patients are more at risk of health conditions associated with the menopause, such as CHS, CVA and osteoporosis if they don’t take HRT.

Early menopause can be caused by a variety of factors such as; viral infections, enzyme deficiencies, chromosome abnormalities such as fragile X syndrome, and Turner’s syndrome. It may also be caused by FSH receptor gene polymorphism and mutation of inhibin B. Other medical factors include hypothyroidism, type I diabetes, Crohn’s disease, SLE, rheumatoid arthritis, Addison’s disease and myasthenia gravis.

There are other factors of a secondary nature which include chemo/radiotherapy, or oophrectomy.

Assessment and diagnoses will require blood tests for FSH, if necessary two weeks apart if there is no calculable cycle, bloods for testosterone, prolactin (to exclude polycystic ovary syndrome) TSH, progesterone (for fertility). Chromosome analysis for fragile X syndrome may be required, also the assessment ought to include a BMI, BP and bone density scan.

Because women with early onset menopause are at greater risk of the associated conditions, it is essential that they are screened initially and also that these checks are made regularly. Patient education regarding reversible risks factors of these conditions is vital.

For early menopause, HRT or a combined contraceptive pill can be prescribed; particularly as contraception still needs to be considered.

Summary of Chest Pain Triage in Primary Care

Urgent referral to A&E is needed for patients presenting with:

  • ACS: crushing/squeezing chest pain at rest, possibly accompanied by nausea, sweating, shortness of breath or dizziness, pain radiation from left arm to jaw may be present.
  • Aortic aneurysm dissection – symptoms include sharp tearing pain, dyspnoea, syncope, a feeling of impending doom.
  • PE – includes symptoms of sharp sudden pain in a patient with a history of recent inactivity/stasis – perhaps recent long-haul travel, recent surgical procedure under general anaesthetic or hospital admission which has restricted normal level of activity, breathlessness.

Chest pain not necessarily requiring urgent transfer to A&E:

  • Angina – similar symptoms to ACS, but pain experienced on exertion and relieved at rest (possibly with a history of CVD). If the patient is unstable patient should be treated along the lines of ACS. Treat initially with GTN.
  • Chest infection/pleurisy; patient will present with pain on moving or breathing, presents as sharp central pain. Patient may also have a fever. This can be safely treated in primary care setting.
  • Pericarditis; again, symptoms as pleurisy, to be treated with NSAIDs if suitable for patient, consider outpatient ECG.
  • GORD – burning pain, retrosternal. May have a long history, possibly associated with particular foods. Not particularly urgent unless presenting with malaena or haematemesis. Patient may require gastroscopy; primary care may involve PPIs or H2 blockers.

It is vital to take a detailed history, as well as appropriate observations (BP, ECG, pulse, respiratory rate, temperature).

P – Provocation/palliation – what triggers the pain? What relieves it?

Q – Quality – what is the pain like? Stabbing, crushing, aching, dull, tearing. Also use pain scale.

R – Radiation – where does the pain begin, and where does it radiate to?

S – Site – what’s the location of the pain?

T – Timing – when did the pain start? What was the duration? How many episodes have there been? When did the episodes start? Is it getting better or worsening?

Also, record any accompanying symptoms such as dizziness, nausea/vomiting/burping, feeling of impending doom, syncope.

Symptoms suggesting ACS need urgent referral to hospital. If this is the case, the patient should be given 300mg aspirin and high-flow oxygen.

About Lymphoedema and its Management

In 2003 studies were carried out which found that there were at least 100,000 people in the UK who were living with some type of lymphoedema, although this is a conservative estimate, and there could well be 200,00 Britons with lymphoedema (Moffatt 2003).

The lymphatic system maintains homeostasis by transporting interstitial fluid which contains protein, waste products and water back into the blood supply (Keen 2008). If this system fails, or is impaired, protein and fluid can accumulate in the tissues, attracting more water by osmosis which then results in a clearly visible swelling. This is known as lymphoedema (Huit 2000). A sign of lymphoedema is when there is an inability to pinch up a skin fold at the base of the second toe – this is known as Stemmer’s sign (Keen 2008). Oedema ‘pits’ when pressed, and after a few seconds the pit will disappear as the fluid returns (Nigam 2008).

Primary oedema is caused by filiaritic infection caused by mosquito bites (more prevalent in the developing world), congenital conditions such as Milroy’s disease (MacLaren 2001). Idiopathic lymphoedema is thought to occur when there is an underdevelopment of lymph vessels (King 2006).

The most common cause of lymphoedema in the UK is due to cancer treatment such as surgery or radiotherapy which cause damage to lymph nodes or removes them completely (MacLaren 2001). This is known as secondary lymphoedema, it can also be caused by trauma, inflammation (including inflammatory arthritis), or infection such as bacterial cellulitis, tuberculosis or filarial infections (Keen 2008).

Common causes of oedema are pregnancy, immobility, varicose veins and cardiac failure. All of these can contribute to the impairment of the lymph vessels’ ability to transport interstitial fluid back to the blood. Cardiac failure can result in pooling of venous stasis, pooling in the legs, which then puts pressure on the venous system, this can lead to pulmonary oedema (Nigam 2008).

Lymphoedema is not a condition that can be cured, but it can be controlled, and through treatment patients can improve their mobility, decrease the impact inflammatory episodes have on their lives, and enhance their quality of life (Huit 2000). If treatment is not initiated, the condition will gradually become worse. After time, as a result of the accumulation of the excess interstitial fluid, fat and fibrous deposits appear (King 2006). The tissue hardens and the oedema no longer pits; in such cases hyperkeratosis is common (excessive growth of skin to form scaly, horny layers), as is papillomatosis (preponderance or wart growths), and lymphorrhoea (leakage of lymph fluid) (Keen 2008), in some cases if oedema continues, massive oedema known as elephantiasis can develop as the lymph vessels become almost completely blocked, ulcers can also develop which are difficult to heal (Nigam 2008). Because the lymph fluid is protein rich, bacterial and fungal infections are common, which increases the risk of acute exacerbations (Huit 2000). Cellulitis can occur during an acute inflammatory episode and should be treated with broad-spectrum antibiotics (King 2006).

Accurate diagnosis, treatment and patient education of lymphoedema is essential if the best outcomes are to be achieved (Huit 2000). It is also important to diagnose the cause of lymphoedema in order to rule out other causes such as cardiac failure, hypertension, lipoedema, protein deficiency, DVT, or immobility. Defining the cause will ensure the most effective treatment and therefore the best outcome. Clinical presentation, previous medical history, and the results of investigations are all invaluable in determining the cause (King 2006).

Treatment (not cure) is aimed at reducing the oedema and encouraging improved lymph fluid flow (King 2006). There are several principles in the treatment and management of lymphoedema: skincare, compression, exercise, and lymphatic drainage (King 2006). From these four points, it is clear to see how essential patient education is, and how patients themselves can ensure the effectiveness of the treatment prescribed. As with all care planning, the patient should be involved in decision-making and should therefore to be able to give informed consent to proposed treatments.

It is likely that for treatment to be effective, the patient will need to make some lifestyle changes, such as increasing the level of activity and exercise taken, making changes to diet by reducing the intake of salt, and losing weight. Also patients may need to develop new habits such as elevating the affected limb(s) to aid venous return, (oedema responds to gravity and therefore if the affected limb is elevated, this assists in the drainage of the fluid back into the blood supply (Nigam 2008)), taking prescribed medication regularly, and adopt the use of compression garments (Nigam 2008). Because this may mean significant changes to a person’s lifestyle, it is particularly helpful if information can be written down for the patient in order for them to refer back to it in the future (Honner 2009).

Good hygiene and skincare is vital for people living with lymphoedema; the aim is for the skin to be kept supple, healthy and hydrated. Even tiny breaks in the skin can lead to infection (Huit 2000). Soap should be avoided as it removes the natural oils that exist to protect the skin, making it more fragile and prone to breaking. Therefore emollients should be used instead such as aqueous cream. Skin should be patted dry, and care must be taken when moisturising that products are not rubbed into the skin, but rather smoothed over the skin in a downward direction (the direction of the hair) this reduces the risk of folliculitis (Penzer 2003). Skin should be inspected daily for any signs of inflammation discolouration or breaks in the skin, as these could signal an inflammatory episode (King 2006). Patients should also be advised to take care of their affected limbs to reduce the risk of injury to them, wearing footwear at all times, or gloves when gardening or washing up, and using insect repellents and sun block adequately (King 2006).

Compression garments or bandaging can be applied to provide a graduated compression to aid vessels transporting the lymph fluid back into the blood supply, it can also prevent the oedema occurring (Huit 2000). In patients with mild oedema where the shape of the limb has not been distorted and with no contraindication (such as arterial disease, cardiac failure, VTE, or allergies), compression garments can be applied immediately with great effect. Patients need to be assessed and measured for their suitability and sizing for compression garments or bandaging (King 2006). Such garments need to be worn daily if they are to achieve their purpose. Again, this is why patient engagement is essential; without concordance most lymphoedema treatments will fail. For patients with more significant oedema, a period of intensive treatment with compression bandages may be required to reduce the oedema and develop a normal shaped limb in order to fit with compression garments. All of this needs do be done and prescribed by an adequately trained practitioner (King 2006).

Exercise is a good way of decreasing oedema, however, because the oedema itself can be a reason for limited mobility any exercise plans should be tailored for the patient’s needs and abilities (Woods 2004); if compression garments have been prescribed, they will need to be worn during exercise (King 2006). Exercise should be moderate, introducing new exercises gradually and not overdoing it. Low impact exercise such as cycling, swimming and walking are advised (MacLaren 2001).

Lymphatic drainage massage works by promoting the removal of interstitial fluid away from the oedematous areas. It should only be performed by a competent [practitioner as the technique is substantially different from regular massage techniques (Huit 2000). This is a particularly good form of treatment for those patients who are unable to tolerate compression treatments for whatever reason. Again patient involvement is vital – patients can be taught to perform this technique on themselves, which can prove effective (King 2006).

The management of lymphoedema can be difficult, there are many factors to consider, causes, contraindications to treatment, patient concordance, education and lifestyle. The more involved the patient is in their treatment, the more likely it is to be effective. Lymphoedema is often overlooked, but if poorly managed can have a seriously negative impact on a person’s lifestyle, body image, and outlook. Therefore it is imperative that lymphoedema is swiftly diagnosed, treatment determined and initiated to minimise distress and inconvenience to the patient (King 2006).

References

  • Honner, A. (2009) The information needs of patients with therapy-related lymphoedema Cancer Nursing Practice. 8, 7, 21-26
  • Huit, M. (2000) A guide to treating lymphoedema Nursing Standard 96, 38 42
  • Keen D.C. (2008) Non-cancer-related lymphoedema of the lower limb Nursing Standard. 22, 24, 53-6.
  • King, B. (2006) Diagnosis and management of lymphoedema Nursing Times 102, 13, 47
  • Lymphoedema Network (2006) Best Practice for the Management of Lymphoedema International Consensus. London. MEP Ltd
  • MacLaren, J.A. MA, (2001) Lymphoedema
  • Moffatt et al, (2003) Lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738
  • Nigam, Y. & Knight, J. (2008) The Lymphatic System Part 4 – Pathophysiology Nursing Times 104, 16, 24-25
  • Penzer, R. (2003) Lymphoedema. Nursing Standard. 17, 35, 45-51.
  • Woods, M. (2004) Causes and treatment of early Lymphoedema Cancer Nursing Practice 3, 5, 25-30

Care of the Post-MI Patient in Primary Care

According to the British Heart Foundation (BHF) in 2006 about 1.3 million people in the UK have had an MI, about 4% of men and 2% of women. Because of their medical history, they will need following up in the primary care setting to help reduce the risk of further events; this is done by a combination of patient education, modification of diet and lifestyle as well as regular checks and medication or further interventions.

In primary care, the major risk factors will therefore be addressed; for example, smoking, obesity, diet, inactive lifestyle, hypertension, dyslipidaemia, poorly-controlled diabetes, as well as ensuring the recommended MI prophylactic medications are prescribed.

Many of these interventions are under QOF with points awarded for specific interventions (such as regular blood pressure checks, blood lipid checks, identification of depression, anxiety or related mental illness, as well as therapies such as ACE inhibitors, beta blockers, aspirin, or angiotensin receptor blockers). It is important for all primary care settings to have robust policies in place for the care of post-MI patients as not all standard therapies are covered by QOF.

Because many of the cardiovascular risk factors are reversible, there needs to be an emphasis on patient education and empowerment. This is the most effective intervention and yet, according to the BHF, less than 40% of post-MI patients have access to this. Primary care nurses are well-placed to provide this.