Ischemic Heart Disease on the CCFP exam

Approach

• Classic angina is pressure or tightness in the chest with effort or stress. It eases with rest.
• Women, older adults and people with diabetes often have no chest pain. Breathlessness, nausea, sweating or sudden tiredness may be all you get.
• In a young patient, chest tightness with exercise plus a parent's early heart attack is a heart question first.
• Ask what moves the heart diagnosis: effort, timing, sweating, breathlessness, past heart disease, family history.
• Skip questions that only refine the comfortable diagnosis. They can wait until the heart is dealt with.
• Diabetes and vomiting? A bedside glucose answers high blood sugar in a minute. Don't spend the history on it.
• Get an electrocardiogram (ECG) now. For the blood test, use troponin, the heart-injury marker.

Approach

• Let the patient choose which risk to work on first. Agree on one or two goals and a date to review them.
• Ask every adult about smoking. Offer advice or counselling, a medicine, or both: varenicline, nicotine replacement, bupropion or cytisine.
• For adults, the Canadian Task Force suggests against e-cigarettes as a way to quit, except in some cases.
• For FH from age 10 to 17, atorvastatin is licensed after a trial of diet. That covers boys and girls after their first period.
• Start it if LDL stays at 4.9 mmol/L or more. Start at 4.1 or more with early heart disease in the family, or two other risk factors.
• Before a statin, rule out other causes of high LDL: poorly controlled diabetes, low thyroid, protein loss from the kidneys, liver disease, alcohol.
• Keep working on vaping, food and activity alongside the statin, not instead of it.

Approach

• A resting ECG between episodes is often normal. It cannot show ischemia (too little blood flow to the heart muscle) that only comes with effort.
• Hold hard exercise until the heart question is answered. Refer for assessment now, not next month.
• One normal troponin soon after the pain began does not rule out a heart attack.
• Use troponin I or T. Don't order CK-MB or myoglobin, older markers, to diagnose a heart attack.
• Suspect a clot in the lung? Score the risk with a rule such as Wells before a D-dimer, a clot blood test, or a scan.

Approach

• Teach the spray: sit and rest, then 1 or 2 sprays (0.4 mg each) on or under the tongue. Do not inhale it.
• If pain continues, repeat up to twice, 5 to 10 minutes apart. Pain that persists means emergency care.
• No nitroglycerin with sildenafil, tadalafil, vardenafil or riociguat. Blood pressure can fall severely.
• Warn about headache and dizziness. Sitting down first lowers the risk of fainting.
• Carry a spare spray. Don't stop long-acting nitrates suddenly: attacks can come back harder.
• Match the contact to the change (table below).

Approach

• Ask how often angina comes, and how much nitroglycerin she uses.
• Ask how she takes each medicine and what she misses. Stopping ticagrelor early could raise the risk of death or another heart attack.
• Ask what she can do now: chores, caregiving, work, sex, driving.
• Review smoking, activity, food and weight at every visit.
• Screen for complications: breathlessness, ankle swelling, palpitations, fainting, low mood.
• Offer cardiac rehabilitation soon after the event. Offer a home-based program when a centre is hard to reach.
• Don't order yearly stress imaging in a patient who is well. It rarely changes care.

Approach

• Read the ECG first. ST elevation means an artery is likely blocked and needs opening now.
• Tenecteplase, a clot-busting drug, is licensed for an evolving full-thickness (transmural) heart attack. Give it as soon as possible after symptoms start.
• No ST elevation: no clot-busting drug. Call the cardiac centre to plan next steps.
• Shock, ongoing pain, a dangerous rhythm or fluid on the lungs: call the cardiac centre now.
• No clot-busting drug given? Give acetylsalicylic acid (ASA) with ticagrelor: 180 mg once, then 90 mg twice daily. Keep ASA at 75 to 150 mg a day.
• Ticagrelor needs no dose change for age or kidney function. Avoid it with active bleeding, a past brain bleed or moderate to severe liver disease.
• Hold nitroglycerin in shock or very low blood pressure. Take care in an inferior heart attack that involves the right ventricle.