Murugan's CARDIOLOGY IN DAY TO TODAY PRACTICE

·         Once a patient is diagnosed to have CAD, (coronary artery disease ) Patient has be treated

 as having CAD for life time. Statins and antiplatelets to be continued  life long for all. ACEI &         

 beta blocker are  also beneficial for  majority of patients.

·        There is no cure for CAD.  Whatever the treatment we do, like PTCA with Stenting or CABG will only reduce the severity of disease.

·        Hence best strategy to tackle CAD is its  prevention.

·       Prevention of CAD should start from child hood, focusing on diet, exercise, maintaining body weight, Stress reduction, etc.

·        Normal ECG, Normal ECHO and Negative TMT will not rule out CAD.  Meticulous history taking is essential in diagnosing CAD.

·        All T inversions that we see commonly in the ECGs  need not represent CAD. Many a times it is due to non coronary causes or normal variants. Morphology of the T wave (symmetrical and

     arrow head ‘T’)  and clinical scenario are important in decision making.  Investigations like   

     Troponin, Echo and TMT also guide us.

·        Troponins will be elevated in the blood 6-12 hrs after acute coronary syndrome.  Hence Troponin, taken before 12 hrs will not rule out CAD.

·        In patients with Acute MI. Primary PTCA is the treatment of choice, provided it is feasible with in 1 ½ hrs of first medical contact.  If not feasible, he has to be thrombolysed. Though thrombolysis can be done upto 6 hrs of pain onset, if it is done within one hour,  (golden hour) the salvage of myocardium and the outcome will be better.  So time is myocardium.

   

·        CT  Coronary angiogram is an evolving tool for diagnosing CAD.  However for assessing the severity  of stenosis of Coronary arteries, Catheter based coronary angiogram is superior to  CT angiogram.  Hence if CAD is strongly suspected, it is better to go for catheter based coronary angiogram.

·        In patients with CAD, after non cardiac surgery, Antiplatelet agents that were stopped, should be restarted at the earliest. Example after 6 hrs of surgery. Delay in or forgetting to restart  antiplatelet  agents is one of the  common and preventable cause for post op MI.

·        In patients with CCF, during inter current  illness liker Fever, Diarrhea,Vomiting – where

      there is chance for dehydration and hypotension.  -  DIURETICS, ACEI and  ARBS should

      be  stopped with close monitoring of volume status and BP and they are to be  restarted

      gradually.  This will prevent the development of ARF.

·        NSAID intake is one of the common cause for worsening of CCF and pulmonary oedema in patients with CCF.  Hence in patients with CCF- It is better to avoid NSAID including coxibs.  Most of the pain can be effectively managed with Paracetamol, Tramadol, muscle relaxants and physiotherapy.

·        One of the common cause for hospitalization in patient`s with CAD & CCF is non compliance and discontinuation of medication.  It`s our responsibility to educate and  convince the      patient  about uninterrupted continuation of medications.

·        As per the concept in 1990^s, beta blockers were contra indicated in CCF.  Currently beta blockers namely – Carvidilol, Bisoprolol and Metoprolol are the main stay of therapy in CCF.  

 

·        In the treatment of SHT the concept  in 1990^s was to start with single drug, go to maximum dose and then add another drug and so on.  Current concept is to start with lower dose of one or two drugs dependent on the levels of BP, then add another drug instead of increasing the dose of the first drug.

·        According to current guidelines beta blockers are not the first line antihypertensives.  ACEI,

      ARBS, CCB and diuretics are the first line drugs.