Aspirin for Primary Prevention

May 6, 2022 Andrew To

Aspirin use in primary prevention is controversial, contrasting that of secondary prevention. It may offer benefit in some, but for most, risk-benefit analysis may argue against its use. Here is the discussion.

My approach to chest pain

September 7, 2019 Andrew To

Severe coronary non-calcified atherosclerosis with severe stenosis, on CT coronary angiography

Chest pain presentations are common, but management can be variable and difficult to understand. Here is my approach:

Beta-blockers in Hypertension

September 5, 2019 Andrew To

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.

Fish oil supplement? - update 2018

September 3, 2018 Andrew To

Daily supplementation with marine-derived omega-3 fatty acids has been promoted for its potential health benefits in cardiovascular diseases. We blogged about this last year with a meta-analysis from Oxford. Here is the update.

The promised randomized controlled trial has now come out after the European Society of Cardiology Congress in Munich last week.

Individual risk assessment - a common scenario

September 4, 2016 Andrew To

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

CT coronary angiography - Cases

March 6, 2016 Andrew To

Curved reconstruction in CT coronary angiography

A 45-year-old man with no prior cardiac history, but with cardiovascular risk factors including a 10-pack-year smoking history stopped last year, 5-year history of Type II diabetes on Metformin, obesity with BMI of 37, without a family history of premature coronary artery disease, now presented with exertional but inconsistent central chest tightness.

He was investigated extensively, including a negative exercise tolerance ECG at 13 minutes without symptom or ECG change. Despite reassurance, his chest pain continued at random, and has not resolved with a course of Omeprazole for presumed non-cardiac (possibly gastrointestinal reflux) chest pain.

What should we do?

- Reassure him that this pain is almost certainly non-cardiac

- Perform a stress echocardiogram as it has a higher sensitivity than an exercise ECG

- Perform an invasive angiography

CT coronary angiography - How good is it?

March 6, 2016 Andrew To

CT coronary angiography - volume rendered image of the left anterior descending artery and its branches

CT coronary angiography has now been routinely performed, at least in the Waitemata area since 2011, where we were the first to implement CTCA in the workup of acute chest pain in New Zealand.