Introduction.
A systematic approach to any subject is
essential to reach at proper management of any clinical problem. Systematic
approach, of course, consists of physiology, anatomy pathalogy etc leading to
clinical medicine and then to pharmacology and therapeutics. The only readily
available source of CME in our settings is off and on clinical meetings; we
attend on different forums. Lectures by teachers on different platforms for
practicing physicians are the only source of whatever uptodate knowledge we
have. Cardiology is favourite subject on these forums. Hypertension, IHD, CCF,
etc are discussed with good frequency. Even then our prescriptions do not
indicate good enough rationality. Basic reason understands of lack of basic
principals involved.
This month we have decided to adopt a very unconventional approach. The points
which are discussed usually at the end o almost all presentations
i.e.treatment tips are being discussed right in the beginning. Rather we are
holding the issue by this tail. An upside down elephant. Only very competent
and accomodating teacher could have agreed on this approach. Prof Ashfaque
Khan has obliged us. Questions in this interview are being ommitted. Contents
of this talk, if appear incohesive or out of order or out of context, this is
only due to our type of questioning. Format of questioning was too informal.
Let us hope this is beneficial to all ou us. Our first question was
Short comings of Family Physicians.
On hypertension
¨ Dosage is seldom adequate.
¨ Combinations of different groups are inapprpriate.
¨ Emphasis on life long use of these drugs, to the patients is lacking.
¨ Due importance to concomitant diseases is lacking.
I H D
¨ Judiceous use of Beta-blockers is missing. Nitrates and calcium blockers are being oversues, while beta-blockers are bein underused.
¨ Antiplatelet drugs and anticoagulants are not being prescribed.
¨ Management of AMI is severly lacking. What must be done by family physicians is not being done.
CCF
¨ Ace inhibitors are being neglected.These should be used more frequently
¨ Concomitant use of calcium channel blockers may be harmful in CCF, especially if IHD is also present.
¨ During the use of diuretics proper concern OT intravascular volume and maintenance of fluid input/output is being neglected. It is especially true in cases of subgroups of patients who have hyperaldosteronism.
¨ Concomitant renal failure is inappropriately managed.
Valvular lesions
¨ Foremost importance should be given to earliest possible assessment for surgical options. This is much delayed. Family physicians must share the responsibility and they can contribute a lot on this front.
¨ Prophylaxis for subacute bacterial endocarditis in these patients is being overlooked.
¨ Use of betablockers to slow down heart rate in these cases should be tried. Mitral stenosis is most common in young age groups. They should be given betablockers.
¨ In Aortic stenosis vasodilators and ionotropics drugs may be harmful.
Obesity, Exercise, smoking and change of life style &Lipid lowering efforts
Advice on these issues is not being implemented by majority of patients.
~Reasons for this noncompliance are
~social taboos,
~eating habits,
~social set up where eating is most of the times only source of enjoyment and
relaxation.
~Local recepies are fattening, contain lot of oil.
~Lack of public awareness and lack of education
~poor motivation.
Still we must do our duty and keep on educating public on these issues. Certainly a time will come when our efforts will create new taboos and new awareness in public minds. Next generation will be more responsive only due to our persistent efforts.
Highly educated and highly motivated persons usually accept advice. They should be properly guided.
Pregnancy induced Hypertension
v These patients are usually volume depleted. Risks for thromboembolic phenomena are greater. These two points should be kept in mind.
v Ace inhibitors are absolutely contraindicated.
v Diuretics are contraindicated.
v Aldomet is time-tested drug. It can be used.
v Calcium channel blockers are quite safe and should be used.
Use of Aspirin
ü In eastablished cases of Ischaemic heart disease, continous use of aspirin is definitely beneficial.
ü It can be used where multiple risk factores for ischaemic heart disease are present even in the absence of any active problem.
Acute Myocardial infarction
A Relief of pain
It must not be delayed. No compromise must be made on supply of morphine and pethidine. Availability must be ensured. If this is not present and synthetic narcotics must be used. Pain must be relieved immediately without any consideration for shock, hypotension or arrythmia. Adequate dosage must be used. Any dose which relieves the pain.
B Hypotension
If systolic pressure is lower than 70,Dubutamine must be started by family physicians immediately. It is an important part of emergency management. Dose is 5 microgram/kg. Patient should be refered with this I/V infusion.
In-patients with acute inferior wall infartion about 30 % patients have right ventricular wall infarction. This induces GIT upset including vomiting. These patients are usually volume depleted .300 mls of normal saline should be given to improve filling of Rt ventrice. This may improve hypotension. If patients impove then another 500 mls of normal saline can be given in next few hours.
Use of nitrates in such patients should be avoided.
C Acute phase vagotonia.
If heart rate is below 50, use of atropine can be life saving. It should not be delayed. Dose is 1 mg. It is quite safe.
D Thrombolytic therapy.
300 mgs chewable aspirin should be given immediately
Then preparations like streptokinase must be given by family physicians. Fears about therapy induced arrythmias are mostly illfounded. If there are isolated arrythmias after this kind of therapy, it should be rather reassuring. These are the evidence of reperfusion. These are usually benign.
E Arrythmias
Isolated arrythmias usually need no immediate therapy. These can be ignored or Lidocane 50 –100 mgs can be given as bolus dose, to be followed by slow I/V infusion in hospital.
If arrythmia is ventricular tachycardia or multifocal, it needs immediate cardioversion.
F Fears of Family physicians on management of AMI
On one hand there is moral responsibility of doctor to do immediately what is required to save life and on the other hand there are fears of mortality and side effects of above mentioned therapy. Only solution is hand on experience in cardiology units for 2 or 3 days.
Paraoxysmal Atrial Tachycardia.
v Acute episodes with narrow QRS complexes should be managed by intravenous verapamil 5 mgs. Verapamil should also be used for recurrent attacks.
v Episodes with wide QRS complexes are to be managed with DC cardioversion.
Status of Digoxin
It is still useful drug. We have become more knowledge about it. It is not truly ionotropic drug. It mainly works by AV block thus reducing heart rate. That is the way it is useful in Atrial fibrilation. Dosage recommended previously was on higher side. Its use should be avoided in
v Acute Ischaemia
v Electrolytes imbalance.
v Advanced renal failure.
Atrial fibrilation
v In young patients cause is usually mitral stenosis
v In old patient’s hyperthyroidism,IHDand hypertension is usually the causes. In this age this may be the only manifestation of hyperthyroidism.
v Digoxin and betablockers should be used to slow down heart rate.If Rt atium is small,it may be possible to revert back to sinus rythem.If Rt atrium is of large size ,then probably sinus rythem may not be feasible idea.Ventricular rate should be slowed down
v One very important point should be kept in mind. Uptill 2 weeks after reverting back to normal sinus rythem, atrial muscles are practically paralysed due to fatigue. Although electic activity is present, effective contractions are absent. During this period patient is at high risk FO clot formation in atria and then embolism. Aspirin should be used. If structural heart disease is present then warfarin sodium should be used with proper monitoring.
Diabetics
All ace inhibitors reduce microproteinuria so delaying renal failure. Ace inhibitors are first choice. Beta-blockers mask hypoglycaemia.
Renal failure
v If creatinine is below 2 mgs, Ace inhibitors are drugs of first choice.
v If creatinine is more than 2 mgs, then calcium channel blockers, prazocin and trazocin should be used.
v Diuretics can be used. Two considerations must be kept in mind. Intravascular volume should be maintained. These must not be potassium sparing.
v Only those betablockers should be used for which main route of excretion is liver. Metoprolol is prefered in such cases over propranolol and atenolol.
v Diuretics
v Basically these should be used to manage flluid overload.
v Metabolic disturbances like hyperuricaemia are really important in clinical practice.
v These are still being used as mild antihypertensives.
Portal Hypertension
Cirrhosis of liver and hypertension is not a common combination. In cirrhosis of liver betablockers should be used with caution and in reduced dose. Liver excretes Betablockers. Nadolol is being used in reduced dose in cases of portal hypertension associated with cirrhosis of liver.
Role of anxiolytics and antidepressents
There is no role for these drugs as antihypertensives. These should be used only if definite anxiety or depression ar present.
Different brands.
Last question was about use of different brands of same salt. Expensive brands and same availabe in much cheaper price. Can we save money on this front for patients? He was of the opinion that certain cheap brands are as effective as expensive ones. While others are not so. He advocated that doctors should make their own experiment and find out.