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

Are cardiologists obsessed with statins?

September 4, 2016 Andrew To

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?!”

Atrial Fibrillation and Coronary Artery Disease: Aspirin and Oral Anticoagulants

March 14, 2016 Andrew To

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 alone

Dual anti-platelet therapy and non-cardiac surgery

March 14, 2016 Andrew To

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.

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.

Treatment of hypertriglyceridemia

August 30, 2015 Andrew To

45M with no other cardiovascular risk factor, presented with HDL 0.6, LDL 2.6, triglyceride 4.5; no prior ischaemic heart disease; failed lifestyle modifications

What should we do with a high triglyceride, low HDL, but reasonably normal LDL?

Vitamin D and stain myalgia

August 30, 2015 Andrew To

55M IHD with prior stents; prior myalgia with Simvastatin and Atorvastatin; but yet still more myalgia with Pravastatin. The treating physician decided to check his vitamin D level and his coenzyme Q10 level.

Which one, vitamin D level or coenzyme Q10 level, is relevant in statin myalgia?

Statin Intolerance - the 2015 Approach

August 30, 2015 Andrew To

Scenario = 55M IHD with stents, trialed simvastatin, atorvastatin and pravastatin, all causing myalgia, without CK rise

Question = what to do?