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Brian’s Life After His Acute
Coronary Syndrome
Tim Sutton, Cardiologist
Middlemore Hospital and Auckland Heart Group
A partnership between the patient
and their health professionals
Cardiac Rehabilitation
Education
Cardiac rehab nurse specialists / practitioners
Dietician
Pharmacist
Physiotherapist
Cardiologist
Empower patient : Know your figures
What has happened in the heart artery?
Healing
Shallow plaque
Obstructive plaque
What is happening in the vascular wall?
Cardiovascular risk factors
Modifiable
Dyslipidaemia
Stress
Sedentary
lifestyle
Hypertension
Smoking
Diabetes
Non modifiable
Age
Family history
Gender
Lifestyle Changes
Dietary change
Fats : less than 30% of daily intake Saturated fats : < 10% intake
No transfatty acids
Salt intake Aim max 2-3g per day
Fruit and veg (400g / day)
Lifestyle
ExerciseAt least 30 minutes of moderate exercise per day
through leisure time, daily tasks and work related physical activity
“For people with time constraints this physical activity may be accumulated in bouts of 8 to 10 minutes”
Weight control – encouragedAim BMI < 25 and waist < 100cm in men and 90cm in
women
AlcoholAim maximum of 3 units per day
Lifestyle
Smoking cessation
Ask all people if they
smoke
Brief advice to stop
smoking
Cessation support
Occupational issues
- drivingMedical Condition Class I or 6 licence Class 2,3,4 or 5 and or a
Passenger
Angina pectoris
(proven) minimal
Individuals with angina pectoris at rest
or minimal exertion should not drive
Same as private classes
Angina pectoris
(suspected)
When suspected fitness to drive is as
for proven angina pectoris
Same as private classes
Uncomplicated ACS No driving for 2 weeks – return subject
to specialist assessment
Should not return to driving for 4
weeks subject to specialist review
CABG No driving for 4 weeks – return subject
to specialist assessment
No driving for 3 months– return
subject to specialist review
PCI No driving for 2 days– return subject
to specialist assessment
Should not return to driving for 4
weeks subject to specialist review
Vocational driver specialist assessment Ejection fraction equal to / above 40%
No evidence of inducible ischaemia on adequate stress test (>9 mins of Bruce ETT)
If revascularised and ischaemia must shows angiographic success
VF within 48 hours of MI – no inducible VT at EP study
Exercise and the Heart : A helping hand for erectile dysfunction
Sildenafil and the heart
Sildenafil is contraindicated in patients on any long acting nitrate
If a patient uses GTN on a symptomatic basis should judge effort tolerance and balance risks vs benefits. No GTN for 24 hours post dose
If a patient can manage > 5-6 mets on an ETT without ischaemia the risk of coitus, with a familiar partner, in familiar settings, without prior alcohol / food is probably low
Disclaimer: we wish to stress that the physical emotional stress on intercourse can be excessive in some people, particular those who have not performed this activity for some time and who are not in good condition
The LDL in atherogenesis
Lipid control
All patients should be on a statin irrespective of their cholesterol
What should we aim for….LDL < 2.0
Reduction of 30% in LDL
“Other lipid lowering agents are not recommended, either as an alternative to statins or in addition to them” //www.who.int/cardiovascular_diseases
How do we raise the HDL?
Aiming HDL >1.0 and TGs < 1.7
Is there are role for additional therapy with fibrates?
High triglycerides
Low HDL
Blood pressure
At least under 140/85
In possible 130/80 especially in
Diabetics
Chronic kidney disease
microalbuminuria
Diabetic Control
Aim HbA1c 50-55
Avoid hypoglycaemia
Role of ACE inhibitors / ARB
Heart failure syndrome
Documented LV impairment (LVEF < 45%)
Diabetes
Renal dysfunction
Microalbuminuria
Second MI
Hypertension
Aldosterone Receptor Antagonists
Clinical heart failure syndrome
LV impairment
3rd heart sound
Antiplatelet therapy
Aspirin
Clopidogrel / Prasugrel / Ticagrellor
Anticoagulation
Warfarin
Can be used as secondary prevention in
isolation (if no Drug eluting stent in place)
Dabigatran
Not proven as secondary prevention agent
and should be combined with aspirin
Prevention is not a cure
Treatment is for life
Seek urgent medical attention for
recurrent symptoms
According to the AHA statement on
usage of sildenafil in patients with
cardiovascular disease….
A. The average male heart rate during coitus is
127bpm with energy consumption 3.3 METS
B. Sudden death during coitus accounts for
0.6% of all sudden deaths
C. The most at risk individual is middle aged
and having extramarital relations
D. All of the above
