HEALTHY “CARDIO”

Cardiac health intro:

Ischaemic heart disease (ihd)is the most common cause of death worldwide encouraging cardiovascular health is not only about preventing ihd health entails the ability to exercise, and enjoying vigorous activity (within reason) Is one the best ways of achieving health, not just because the heart likes it (⬇️BP, increased good highdensity lipoprotein (HDL)  it can prevent osteoporosis, improve glucose tolerance., and augment immune function (eg in cancer and if HIV+ve). People who improve and maintain their fitness live longer: » age-adjusted mortality from all causes is reduced by >40%. Avoiding obesity helps too, but weight loss per se is only useful in reducing cardiovascular risk and the risk of developing diabetes when combined with regular exercise. Moderate alcohol drinking may also promote cardiovascular health.

Hypertension is the chief risk factor for cardiovascular mortality, followed by smoking. Giving up smoking, even after many years, does bring benefit. Simple advice works. Most smokers want to give up. Just because smoking advice does not always work, do not stop giving it. Ask about smoking in consultations--especially those regarding smoking-related diseases.

"Ensure advice is congruent with the patient's beliefs about smoking.

• Getting patients to enumerate the advantages of giving up ⬆️ motivation.

• Invite the patient to choose a date (when there will be few stresses) on which he or she will become a non-smoker.
• Suggest throwing away all accessories (cigarettes, pipes, ash trays, lighters, matches) in advance; inform friends of the new change; practise saying no' to their offers of 'just one little cigarette'.

Nicotine gum, chewed intermittently to limit nicotine release: 2 ten mg sticks may be needed/day. Transdermal nicotine patches may be easier. A dose increase at lwk can help. Written advice offers no added benefit to advice from nurses. Always offer follow-up.

• Varenicline is an oral selective nicotine receptor partial agonist. Start lwk before target stop date and gradually increase the dose. sEs: appetite change; dry mouth; taste disturbance: headache: drowsiness; dizziness; sleep disorders; abnormal dreams; depression; suicidal thoughts; panic; dysarthria.
• Bupropion (=amfebutamone) is said to 7 quit rate to 30% at lyr vs 16% with patches and 15.6% for placebo (patches + bupropion: 35.5%):' consider if the above falls. Warn of sEs: seizures (risk <1:1000), insomnia, headache.

Lipids and diabetes are the other major modifiable risk factors. The peR 5K2 score (www.qrisk.org)is used in the uk to integrate a patient's different cardiovascular risk factors in order to predict future cardiovascular health.' It can be used as part of a consultation on lifestyle factors to show patients that addressing certain risk factors (eg smoking, bp)  will reduce their risk of MIs and strokes

 

Cardiovascular symptoms

Chest pain • Cardiac-sounding chest pain may have no serious cause, but alvay think 'Could this be a myocardial infarction (MI), dissecting aortic aneurysm, pericar. ditis, or pulmonary embolism? 

Character: Constricting suggests angina, esophageal spasm, or anxiety; a sharp pain may be from the pleura, pericardium, or chest wall. A prolonged (>4h), duf central crushing pain or pressure suggests MI.

Radiation: To shoulder, either or both arms, or neck/jaw suggests cardiac ischae mia. The pain of aortic dissection is classically instantaneous, tearing, and interscapular, but may be retrosternal. Epigastric pain may be cardiac.

Precipitants: Pain associated with cold, exercise, palpitations, or emotion suggests cardiac pain or anxiety; if brought on by food, lying flat, hot drinks, or alcohol, com sider oesophageal spasm/disease (but meals can also cause angina).

Relieving factors: If pain is relieved within minutes by rest or glyceryl trinitrate

(GTN), suspect angina (GN relieves oesophageal spasm more slowly). If antacids help suspect GI causes. Pericarditic pain improves on leaning forward.

Associations: Dysproea occurs with cardiac pain, pulmonary emboli, pleurisy or anxiety. MI may cause nausea, vomiting, or sweating. Angina is caused by coronary artery smeasu-rand also by aortic stenosis, fypert ophier cardiomyopatry (Ho/ paroxysmal supraventricular tachycardia (svT)-and can be exacerbated by ande mia. Chest pain with tenderness suggests self-limiting Tietze's syndrame.' Odd neurological symptoms and atypical chest pain--think aortic dissection.

Pleuritic pain: Pain exacerbated by inspiration. Implies inflammation of tha neura from pulmonary infection, inflammation, or infarction. It causes us breath. A4 musculoskeletal pain,' fractured rib (pain on respiratig by gentle pressure on the sternum), subdiaphragmatic pathology eg (gall stones)

Chest pain & acutely unwell : • Admit • Check pulse, bp in both arms

, Jp, heart sounds, examine legs for DVT • Give 02

• Iv line - Relleve pain (eg 5-10mg Iv morphine) • Cardiac monitor • 12-lead ECG. 
• Arterial blood gas (ABG)  
• Famous traps: Aortic dissection; zoster ; ruptured oesophagus; cardiac tamponade ; opiate addiction.

Dyspnoea: May be from LVF, PE, any respiratory cause, anaemia, pain, or anxiety.

Severity: -Emergency presentations: 782. Ask about shortness of breath at rest on exertion, and on lying flat: has their exercise tolerance changed? Associations Specific symptoms associated with heart failure are orthopnoea (ask about numbe of pillows used at night), paroxysmal nocturnal dyspnoea (waking up at night gasp. ing for breath, p49), and peripheral oedema. Pulmonary embolism is associated with acute onset of dyspnoea and pleuritic chest pain; ask about risk factors for DvT. 

Palpitation(s) :May be due to ectopics, sinus tachycardia, aF, svT, VT, thyrotoxicoss anxiety, and rarely phaeochromocytoma. See p36. History: Characterize: do they mean their heart was beating fast, hard, or irregularly? Ask about previous episodes precipitating/relieving factors, duration of symptoms, associated chest pain, dyse noea, dizziness, or collapse. Did the patient check their pulse?

Syncope: May reflect cardiac or cNS events. Vasovagal 'faints' are common (pulse, pupils dilated). The history from an observer is invaluable in diagnosis. Prodroma symptoms: Chest pain, palpitations, or dyspnoea point to a cardiac cause, eg ar rhythmia. Aura, headache, dysarthria, and limb weakness indicate cNS causes During the episode: Was there a pulse? Limb jerking, tongue biting, or urinary incor tinence? Na: hypoxia from lack of cerebral perfusion may cause seizures. Recovery Was this rapid (arrhythmia) or prolonged, with drowsiness (seizure)?

Extra points:

25% of non-cardiac chest pain is musculoskeletal: look for pain on specific postures or activity. Aim to reproduce the pain by movement and, sometimes, palpation over the structure causing it. Focal injections local anaesthetic helps diagnostically and is therapeutic. Tletzes syndrome: self-limiting costochondritis +/- Costosternal joint swelling. Causes idiopathic , microtrauma, infection; psoriatic/ rheumatoid arthritis.

Treatment : NSAIDs , sterol injections.  

Tenderness is also caused by: fIbrositis, lymphoma, chondrosarcoma, myeloma , metastases, rib TB. 

Imaging: bone scintigraphy; cT.