High risk groups 1,2,3

  • Those who:
    • are overweight/obese and inactive
    • have poor diets
    • are smokers or drink excessive alcohol
    • are of Aboriginal and Torres Strait Islander or Pacific Islander descent
    • are socioeconomically disadvantaged
    • live in rural or remote locations
    • have pre-existing chronic conditions

Urgent referral

1. What is coronary heart disease (CHD)? 1,2,3

  • Leading cause of death in Australia
  • Also called coronary artery disease or ischaemic heart disease
  • Characterised by the slow deposit of fatty plaque on the inner walls of the coronary arteries of the heart
  • Subsequent narrowing of the arteries prevents oxygenated blood from reaching heart muscles causing tissue death (ischaemia) and pain (angina)
  • CHD is characterised as:
    • chronic coronary syndrome (CCS) – partial narrowing of the arteries that causes stable angina typically lasting several minutes and relieved with rest and medicine (glyceryl trinitrate). Intensive lifestyle modification and medicines are required to prevent progression to acute coronary syndrome (ACS)
    • acute coronary syndrome (ACS) – occurs when plaque ruptures or completely blocks blood flow to the heart muscle. This leads to unstable angina (angina occurring at lower levels of exertion or at rest, lasting > 15 minutes), MI or sudden death

2. Diagnosis of CHD 1,2,3

  • Based on clinical presentation, history and risk factors
  • Patients typically present with chest discomfort or pain triggered by exertion; may occur with emotional stress or temperature extremes
  • Chest pain occurring at rest may be from an ACS
  • Associated symptoms include difficulty breathing, dizziness, nausea, sweating or fatigue. Associated symptoms can occur without chest pain in diabetes, renal failure, females, elderly or Aboriginal and Torres Strait Islander persons
  • An ACS may be confirmed by new ischaemic changes to a resting 12 lead ECG, or elevation of the cardiac enzymes (blood results)
  • CCS may be confirmed by evidence of ischaemia on cardiac stress tests
  • Further assessment may include blood test, chest x-ray, coronary angiography and echocardiogram

3. Management of CHD 1

  • Management goals are to stabilise and prevent progression by:
    • behavioural Lifestyle modifications
    • use of medicines
    • identifying and addressing comorbidities, in particular:
      • Dyslipidaemia
      • Hypertension
      • Heart failure
      • Diabetes
      • Chronic kidney disease
      • peripheral vascular disease
      • anaemia
      • thyroid disease
  • Manage according to estimated cardiovascular risk. See the Australian cardiovascular disease risk calculator
  • See Table 2.
  1. Patient self-management support 1,2
    • Provide culturally appropriate information to the patient about CHD:
      • addressing Lifestyle modifications
      • current or future cardiac events
      • attendance to a cardiac rehabilitation program instigated by the discharging facility. See 3.3 Cardiac rehabilitation
      • safe use and adherence to medicines regimen
      • how to manage CHD by developing an action plan. See 3.4 Action plan
      • the need for ongoing monitoring
      • see Resource 1.
    • All patients discharged from an acute facility should have a discharge plan to ensure continuity of care
    • Refer patient to SMoCC, a phone service that supports patients manage their condition. See Resource 2.
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients

­

Table 2. Target goals to manage CHD 1,2

Risk factor

Target

Smoking

  • Cease smoking completely and avoid secondhand smoke. See Smoking cessation

Diet and nutrition

  • 2 serves of fruit and 5 serves of vegetables/day (1 serve = 1 handful)
  • Reduce salt, sugar or takeaway food. See Diet and nutrition

Alcohol

  • ≤ 2 standard alcoholic drinks per day. No alcohol is best. See Alcohol reduction

Physical activity

  • At least 30 minutes of moderate intensity physical activity (that which causes huffing and puffing and increased heart rate) on most, if not all, days. See Physical activity and sleep

Weight

  • Waist circumference for men < 94 cm
  • Waist circumference for women < 80cm
  • BMI of 18.5–24.9 kg/m2. See Overweight and obesity (adult)

Lipids

  • See Dyslipidaemia

Blood pressure

  • < 130/80 mmHg. See Hypertension

Diabetes

  • Fasting blood glucose level between 4.0 and 6.0 mmol/L
  • HbA1c ≤ 7% (53 mm0l/mol). See Diabetes
  1. Social-emotional support 1,2,3,4,5
    • Depression is three times more common in patients after an MI than the rest of the population and:
      • results in a worse prognosis for those with CHD
      • decreases adherence to medicines
      • reduces successful lifestyle behaviours modification
      • reduces participation in cardiac rehabilitation
    • See Depression and Social-emotional wellbeing
  2. Cardiac rehabilitation 1,2,6,7
    • A written plan of staged exercise and activity resumption; developed and commenced by the referring hospital and continued in the community
    • All patients are encouraged to attend cardiac rehabilitation once medically stable, especially Aboriginal and Torres Strait Islander people who:
      • are at higher risk of heart disease and repeat cardiac events
      • have specific cultural needs
      • participate in cardiac rehabilitation at lower rates than non-Indigenous patients
    • Rehabilitation program eligibility are for those:
      • after a MI
      • with unstable or exertional angina
      • with controlled Heart failure
      • after revascularisation or any other cardiac surgical procedures
    • Discuss the benefits of cardiac rehabilitation:
      • improves physical and mental health and quality of life
      • motivates and improves lifestyle behaviours modification and outcomes
      • reduces hospitalisation by up to 56%
      • reduces risk of death by up to 36% within the first year
      • accelerates recovery
      • improves clinical management targets i.e. cholesterol levels, blood pressure etc
      • improves adherence to medicine
    • For cardiac rehabilitation programs see Resource 3.

Flowchart 1. CHD action plan

Flowchart1. displaying an action plan for patients with Chronic Heart Conditions (CHD) presenting with various levels of CHD symptoms

  1. Action plan
    • Develop a written CHD action plan (Resource 4.) with the patient to monitor and action:
      • chest pain, when they get it, how often they get it
      • pattern of pain e.g. frequency, intensity and duration
      • what to do e.g. take certain medicines
      • when to seek help
    • See Flowchart 1. CHD action plan

4. Medicines for CHD 1,2,3,4,5,8

  • Medicines reduce the risk of MI or death and provide relief from symptoms
  • All patients with CHD should be on a statin irrespective of their lipid levels
  • A SSRI is safe and effective to manage depression in people with comorbid CHD
  • SSRI has potential interaction with warfarin. See Safe use of warfarin
  • Oestrogen and progestin agents should not be prescribed for primary or secondary prevention of CHD
  • If hormone replacement therapy is prescribed for other conditions, the risks and benefits must be considered

Table 2. Long-term medicine management of CHD (continued) 1,2,3,4,5,8

Table 2. Long-term medicine management of CHD 1,2,3,4,5,8

Glyceryl trinitrate (GTN)

  • For continuing infrequent episodes of chest pain
  • Advise patient to stop activities and sit before taking medicine
  • Contraindicated with phosphodiesterase 5 inhibitors commonly used for e.g. pulmonary hypertension or erectile dysfunction. May cause profound hypotension. Do not give unless:
    • > 12 hours since last dose of avanafil
    • > 24 hours for sildenafil or vardenafil
    • > 48 hours for tadalafil
    • monitor closely

Glyceryl trinitrate spray 400 microgs subling, repeat every 5 minutes if pain persists, (to a max. of 3 doses) OR

Glyceryl trinitrate tab 300–600 microgs subling, repeat every 5 minutes if pain persists, (to a max. of 3 doses)

Antiplatelet therapy

  • Mono or dual antiplatelet therapy is usually recommended for 12 months after an acute coronary syndrome incident but may vary depending on risk factors as per the cardiologist:
    • < 12 months may be appropriate for patients at high risk of bleeding
    • > 12 months may be appropriate for patients at high risk of recurrent ischaemic events
  • Consult cardiologist for any variation

Aspirin 100–150 mg PO daily plus one of the following

  • Clopidogrel 75 mg PO daily OR
  • Ticagrelor 90 mg PO bd

Statin

  • Statin therapy is recommended for all people with CHD and as primary prevention in those at high risk of CHD irrespective of their lipid levels
  • See Dyslipidaemia

Beta-blockers

  • For haemodynamically stable patients
  • For patients with LV dysfunction (LVEF < 40%), use one of the beta-blockers recommended for heart failure (carvedilol, bisoprolol or metoprolol succinate)
  • Continue beta-blocker therapy indefinitely in high-risk patients with ongoing ischaemia or LV dysfunction

Atenolol  25–100 mg PO daily

Metoprolol tartrate 25–100 mg PO bd

Carvedilol < 85 kg: 3.125 mg PO bd (to max. 25 mg bd). > 85 kg: 3.125 mg PO bd (to max. 50 mg bd)

Bisoprolol 1.25 mg PO daily (to max. 10 mg daily)

Metoprolol succinate MR 23.75 mg PO daily (to max. 190 mg daily)

Angiotensin converting enzyme inhibitors (ACEi)

  • Aim to titrate the ACEi to the maximum daily dose tolerated
  • Monitor for hypotension, kidney impairment and hyperkalaemia
  • Continue long term in patients with heart failure, LV systolic dysfunction, diabetes, anterior MI or coexisting elevated blood pressure

Perindopril arginine (or equivalent erbumine dose) 2.5 mg PO daily (to a max. 10 mg daily)

Ramipril 1.25 mg PO daily (to a max. 10 mg daily)

Captopril 6.25 mg PO bd (to a max. 150 mg daily in divided doses)

Angiotensin II receptor blockers (ARBs)

  • An ARB may be considered for patients who are intolerant of ACEi
  • Contraindications to early ARB use include haemodynamic instability and hypotension (SBP < 90 mmHg)
  • Continue the ARB long term, especially for patients with heart failure, LV systolic dysfunction, diabetes, anterior MI or coexisting hypertension

Irbesartan 75 mg PO daily (to a max. 300 mg daily)

Telmisartan 40 mg PO daily (to a max. 80 mg daily)

Valsartan (non-LAM)* 20 mg PO bd ( to a max. 320 mg daily)

Anticoagulant

Anticoagulants are recommended in those with Atrial fibrillation and in patients who have had a large MI to prevent emboli from left ventricular thrombus

Calcium channel blockers

  • Reserved for patients with post-MI angina and/or elevated blood pressure not well controlled by other drugs
  • Avoid diltiazem and verapamil in patients with left ventricular failure, significant dysfunction (LVEF < 40%) or in combination with beta-blocker

Mineralocorticoid receptor antagonists (or Aldosterone antagonists)

  • Recommended post MI for patients with left ventricular dysfunction (LVEF < 40%), Heart failure or Diabetes
  • Examples include eplerenone or spironolactone

*See LAM and PBS for medicine indications and restrictions

5. Cycle of care

Cycle of care summary for coronary heart disease

Action

Dx

Frequency

Height

Once

BMI

3 mthly

Weight

3 mthly

Waist circumference

3 mthly

Heart rate

3 mthly

BP

3 mthly

FBC

12 mthly

UEC

12 mthly

Fasting lipids

12 mthly

Fasting blood glucose

12 mthly or more frequently if not on target or if medicines recently altered

Urinalysis

12 mthly

ACR

12 mthly

ECG

12 mthly

Risk factor education

3 mthly

Lifestyle modifications

3 mthly

Social-emotional wellbeing

Each visit

Medicine review

12 mthly

Influenza, pneumococcal and COVID-19 vaccines

Recommended. See the Australian Immunisation Handbookfor schedule

MO/NP review

6 mthly

Dentist

12 mthly

HW/RN review

3 mthly

Dietitian

Referral as required

Cardiologist

6–8 weeks post cardiac event/surgery and as required

Cardiac rehabilitation

After cardiac event and anyone (with CHD) who would benefit from lifestyle modification should be referred

CV risk assessment

3 mthly

6. References

7. Resources

  1. Aboriginal and Torres Strait Islander heart disease resources
  2. Self-Management of Chronic Conditions (SMoCC) service
  3. The National Cardiac Rehabilitation Program Directory and Heart Foundation cardiac rehabilitation resources for healthcare providers
  4. A coronary heart disease action plan: Heart attack warning signs

Last updated: November 2024

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