The CARE approach to AF management outlined by the ESC in 2024 succinctly summarises the key management challenges.
Read moreCovid 19 Drug Interactions
Covid 19 remains a problem. From the cardiology perspective, the main issue now is the use of anti-virals and drug interactions.
Paxlovid (nirmatrelvir/ritonavir) is the main drug of concern with respect to drug interactions. Unfortunately, there has been numerous incidents of drug interaction resulting in harm.
Commonly used cardiac drugs that are absolute contraindications to Paxlovid include (but not limited to)
Amiodarone, dronedarone
Flecainide
Propafenone
Ivabradine
Bosnian, Sildenafil, Tadalafil
Here are two great tools to check drug interactions. It is best to double check for each individual patient.
Heart failure medications - dosages
Iris Iris Iris by Dane Mitchell @ Auckland Art Gallery 2019
Heart failure medications save lives.
Dosages are important though, and many patients may not be on sufficient dosages.
Here are a number of tables useful for references, adapted from ACC/AHA guidelines 2013.
Read moreGLP-1 Agonists - FAQ
Effects of GLP-1 RA on CV risk factors/outcomes and practical aspects for the use of these agents; Marx et al. Circumflex 2022;146:1882-1894
GLP-1 agonist is a class of medications that are used in type 2 diabetes and obesity. This is what we need to know
Our approach to CT calcium score
MESA calculator - probability of non-zero calcium score
In primary prevention, CT calcium scoring has been suggested to help decision making surrounding statin use.
Some of the underlying concepts are somewhat complex, but the screening paradigm remains that of matching the intensity of preventive efforts with the individual’s absolute risk.
The appropriateness of CT calcium scoring in an individual patient therefore depends
patient’s pretest probability of atherosclerotic cardiovascular risk
potential benefits of preventive therapies
negative aspects and risks of preventive therapies
patient preference
Primary aldosteronism - the cardiologist's simplistic approach
Aldosterone
Screening for secondary causes of hypertension is important, though often not thought of. Primary aldosteronism is the most common endocrine cause. The screening test is the aldosterone-renin ratio (ARR).
Read moreWhat should I do with heart failure with preserved ejection fraction?
Homage to Mondrian by Nipan Keawkumdee
HFpEF stands for heart failure with preserved ejection fraction. Commonly, it is defined as those with an LV ejection fraction of more than 50%, though varying definitions do exist.
This condition is poorly understood and is difficult to diagnose, because it is largely one of excluding other potential non cardiac causes of symptoms suggestive of HF.
Read moreHypertension treatment – how should we choose?
Billy Apple @ Auckland Art Gallery 2015 (2 Minutes 33 Seconds (Red))
First line agents for hypertension are one of three classes:
- ACE inhibitors or Angiotensin receptor blockers
- Thiazides
- Calcium channel blockers
Drug preference is mainly influenced by co-morbidities and contraindications, rather than a simple age cut-off.
Read moreBeta-blockers in Hypertension
70-year-old asymptomatic man with hypertension but not cardiovascular disease presented for a routine check. His pulse rate was 40bpm. His son, aged 45, recently had an MI in Australia.
His medications include
Doxazosin 8mg OD
Metoprolol 95mg CR OD – since 2006
Cilazapril 5mg / Hydrochlorothiazide 12.5mg OD
ECG shows sinus bradycardia, with normal PR interval, QRS duration.
Read moreBP therapy initiation - Combination vs. Single Agent
Expected BP lowering with different anti-hypertensive classes and dosages.
65M with Type 2 diabetes on oral hypoglycaemics but no proven coronary artery disease, BP 150/95mmHg despite 3 months of intensive lifestyle modifications, not currently on anti-hypertensives. Would you?
- Introduce low dose ACE inhibitors, with gradual up-titration
- Introduce combination ACE inhibitor / thiazide, with up-titration later on
Read moreEndocarditis prophylaxis
Enterococcus faecalis
Antibiotic prophylaxis is suggested for patients with cardiac conditions that confer the highest risk of adverse outcome from infective endocarditis.
Read moreDuration of anti-platelets – a 2018 update
Cumulative Incidence of Major Adverse Cardiovascular and Cerebrovascular Events, According to Study Group. DAPT trial
64F presented with chest pain, consistent with non-ST elevation myocardial infarction with preserved systolic function. At invasive angiogram, right coronary artery was successfully stented with a drug eluting stent. On hospital discharge, she was given Aspirin, Ticagrelor as dual anti-platelet agents. How long should the dual antiplatelet therapy be continued for?
Read moreNocturnal hypertension
Arboria, 2015 @ Aotea Square
65M presented for a general health check, asymptomatic on systems enquiries. BP was 150/90mmHg with no other abnormalities. You decided to send him for an ambulatory blood pressure monitor to establish if more aggressive intervention is necessary. The report states that he is not a nocturnal dipper. His average diurnal BP was 145/85mmHg. Would medications be necessary? Is there anything else we should consider?
Read moreLifestyle changes for hypertension – exactly how effective is it?!
Topolobampo, Chicago, IL
In general practice (and in secondary care), we discuss at length lifestyle modifications that aid blood pressure lowering. But exactly how effective are the various strategies?
There are 5 things we could do to reduce our blood pressure, without medications.
Read moreAtrial fibrillation – is there a role for lifestyle modification?
Chocolate, camote, coconut @ Topolobampo, Chicago, IL
55M presented with first episode of paroxysmal atrial fibrillation proven on resting ECG in the GP practice. Echocardiogram showed structurally normal heart. The cardiologist decided to manage conservatively without starting anti-arrhythmics right now. Which of the following risk factor management should be part of his AF treatment and prevention?
Read moreACC AHA Hypertension Guidelines 2017 – What’s new?
@ AHA Meeting in Anaheim 2017 - taking notes
The ACC/AHA Hypertension Guidelines 2017 was released in the AHA meeting in Anaheim, Californiain November 2017.
While there were a lot of changes, I think it has simplified a lot of the complexities surrounding treatment threshold and goal.
Read more“My cholesterol is almost normal – why do I need statins, doctor?”
Baja hiramasa yellowtail, pineapple two ways, achiote infused agave @Topolobampo, Chicago, IL
Traditionally, we are taught that laboratory tests have “normal ranges”, such as in haemoglobin or creatinine. However, this concept of “normal”, when applied in cholesterol measurement, often creates confusion amongst some clinicians and certainly in most patients.
Read moreNSAIDs and MI risk
One-man-band on St Kilda Road, Melbourne
Nonsteroidal anti-inflammatory drugs (NSAIDs) use is associated with a significantly increased risk for myocardial infarction (MI). This includes naproxen, considered by some as one of the safest drugs in this class. This is according to a new patient level meta-analysis from the University of Montreal, studying celecopxib, diclofenac, ibuoprofen, naproxen and rofecoxib.
Read morePatient centered discussion of primary prevention statin therapy
Mayo clinic Statin Choice Decision Aid
The Mayo clinic has recently published an electronic tool called “Statin Choice Decision Aid”, which is immensely valuable in helping patients visualize cardiovascular risk, and the benefit of statin medications as applied to them.
Read moreIndividual risk assessment - a common scenario
1906 San Francisco Fire Sacramento Street; Photo from Arnold Genthe from the Library of Congress
A 40-year-old Maori man came for routine review concerned because his 38-year-old brother, who was a smoker, died suddenly of a heart attack. The patient was athletic, previously played professional rugby, without clinical risk factors.
- BMI 28
- LDL 4.9; TC/HDL ratio 4
His calculated cardiovascular risk on these parameters was low. A reasonable approach would include
1) reinforcing healthy living and reassessing in 5 years
2) reinforcing healthy lifestyle and starting a statin
3) reinforcing healthy lifestyle, getting a CTCA, starting a statin
4) all of the above
Read more