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. QOF Clinical Indicators
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

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

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

12. 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?

13. Tea break

14. Cardiovascular Chest pain Palpitations Breathlessness Ankle swelling
Dizziness/faints

15. Cardiovascular
Cases…..

16. 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

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

18. 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

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

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

21. Stroke prevention
CHADS2

22. CHADS2 Scoring Scheme Condition Points C Congestive Heart Failure 1 H
Hypertension A
Age >75 years D
Diabetes S2
h/o Stroke or TIA 2

23. CHADS2 Scoring Scheme CHADS2 score Stroke risk % p.a. Risk Therapy 1.9
1.9
Low
Aspirin 1
2.8
Moderate
Choice 2
4.0
High
Warfarin 3
5.9 4
8.5 5
12.5 6
18.2

24. CHA2DS2-VASc Scoring Condition Points C Congestive Heart Failure 1 H
Hypertension A2
Age >75 years 2 D
Diabetes S2
h/o Stroke or TIA V
h/o Vascular Disease A
Age years S
Female

25. Patient Decision Aids National Prescribing Centre (provided by NICE)

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

29. 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

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

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

32. Palpitations - investigations
Bloods
ECG
24h tape
Event recorder

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

35. Chest pain - ?ACS History of pain Cardiac unlikely if
> 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

36. 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%

37. 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….

38. 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

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

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

42. Evaluation forms please….
Thank-you!
Evaluation forms please….