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 More
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 More
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 More
First line agents for hypertension are one of three classes:
- ACE inhibitors or Angiotensin receptor blockers
- Calcium channel blockers
Drug preference is mainly influenced by co-morbidities and contraindications, rather than a simple age cut-off.Read More
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 More
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 onRead More
Antibiotic prophylaxis is suggested for patients with cardiac conditions that confer the highest risk of adverse outcome from infective endocarditis.Read More
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 More
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 More
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 More
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 More
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
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 More
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
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 More
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 aboveRead More
Sam is a 60-year-old male heart attack survivor who had an unremarkable recovery after the successful coronary artery stenting in the middle of the night of his presentation. Now it is 3 months and Sam feels absolutely grand. At follow-up, his cardiologist insists that he should continue all the prescribed medications. He read on the internet some bad press about statin medications and thought, “surely, nothing will happen if I stop taking statins?!”Read More
A normally well 76-year-old lady had an NSTEMI 2 years ago and had successful stenting with a drug eluting stent (DES) for a severe left anterior descending artery narrowing. She had residual mild diffuse disease elsewhere.
After 12 months of dual antiplatelet therapy with Aspirin and Ticagrelor, she is now on Aspirin, in addition to Atorvastatin 40mg and Cilazapril 2.5mg for hypertension.
When seen in clinic, she reported no angina but was found to have new incidental asymptomatic atrial fibrillation. She had no history of stroke or TIA.
The best strategy for managing her stroke risk is
1) Aspirin alone
2) Aspirin plus Warfarin
3) Aspirin plus Dabigatran
4) Warfarin alone
5) Dabigatran aloneRead More
A 75-year-old male is now 7-month post anterior myocardial infarction. He had successful proximal LAD drug eluting stent, currently on Aspirin and Ticagrelor. He is awaiting total hip joint replacement, and the orthopaedic surgeon would like to know whether he could stop his anti-platelets.Read More