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Five-minute Practitioner: June 2009

Only got five minutes? Then just read these key points on: cardiac rehabilitation, familial hypercholesterolaemia and anaphylaxis

Only got five minutes? Then just read these key points on: cardiac rehabilitation, familial hypercholesterolaemia and anaphylaxis

Cardiac rehabilitation

Cardiac rehabilitation (CR) is, in effect, a chronic disease management programme with a very strong evidence base. Exercise-based CR results in a 20% reduction in all cause mortality and a 25% reduction in total cardiac mortality.

Other benefits of CR have also been clearly demonstrated. These include: reduction in symptoms in those with angina; increase in exercise capacity and general fitness; reduction in blood pressure; improvement in lipid profile (mainly by raising HDL); reduction in arrhythmias; improved coronary blood flow; and improvement in psychological measures.

GPs can refer CHD patients to an appropriately qualified instructor for Phase IV community-based exercise sessions, using the British Association for Cardiac Rehabilitation (BACR) protocol for GP referral. The BACR exercise referral pathway recommends annual review of the patient by their GP or other designated health professional.

The following patient groups benefit from CR programmes: post-MI; post-revascularisation (either surgical or PCI); stable angina; heart failure; post-valve surgery and cardiac transplantation or ICD insertion.

The BACR Standards and Core Components for Cardiac Rehabilitation set out the minimum standard for CR programmes. The core components reflect that cardiac rehabilitation services are moving away from the traditional model with its focus on exercise, psychological support and education to a more comprehensive approach which includes optimising secondary prevention measures.

The optimal model of cardiac rehabilitation is one that provides these core components but also takes into account the fact that the needs and beliefs of individual patients vary considerably. Programmes are becoming increasingly patient-centred and moving towards a menu-based approach where the patients choose the components most relevant to them.

Familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a relatively common genetic disorder, the heterozygous form affecting 1 in 500 people in the UK. It is caused by mutations in the hepatic proteins involved in the clearance of LDL-C from the circulation. The homozygous form is very rare.

FH accounts for around 10% of all hyperlipidaemias. It is a risk factor for the development of premature atherogenesis, and therefore CHD.

In the heterozygous form of the condition typical TC levels are 7-13 mmol/l (>13mmol/l in the homozygous form). HDL-C levels are typically average or reduced, while triglyceride levels are usually within the normal range (< 1.7 mmol/l). The clinical corollary of this is the development of CHD at an early age if untreated; this is typically in the fourth decade in men who are heterozygous and a decade later in women.

The diagnosis of FH rests on the Simon Broome criteria, essentially, it requires elevation of LDL-C, plus clinical evidence of hypercholesterolaemia such as tendon xanthomata, and evidence of a family history. Patients with definite or possible FH need to undergo further testing which usually requires referral to a lipid clinic.

Anaphylaxis

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and/or mucosal changes.

Clinical presentations of allergy which are not life threatening should not be confused with anaphylaxis. Most patients who have skin reactions alone, do not go on to develop anaphylaxis.

Food, drugs and stings are the most common triggers of anaphylaxis in the UK. Food triggers tend to be more common in children and drugs are far more common triggers in adults.

Anaphylaxis is likely if a patient who is exposed to a known trigger develops a sudden illness (usually within minutes of exposure) with rapidly progressing skin changes and life-threatening airway and/or breathing and/or circulation problems.

Adrenaline is the most important drug for the treatment of anaphylaxis. It seems to work best when given early after the onset of the reaction but it is not without risk, particularly when given iv. Adverse effects are extremely rare with correct doses injected im. Antihistamines and corticosteroids are second-line treatments.

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