Posted in Cardiology -unresolved questions, Cardiology hypertension, cardiology- coronary care, Cardiology-Arrhythmias, Cardiology-Coronary artery disese, Uncategorized, tagged ARBS, bmj, bnp, cardiology, chronic total occlusion, coronary care units, cost effectiveness, cpk mb, CRT, cto, ebm, ethics, ethics in cardiology, ethics in medicine, evidence based medicine, fondaparinux, heparin, hippocrates, hypertension, jacc, jama, jnc6, jnc7, lmwh, nejm, nstemi, pci, ptca, rescue pci, seminars in cardiology, stemi, troponin on August 19, 2009 |
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- Do 64slice MDCT in all patients who has a coronary event and follow it up with catheter based CAG.
- Use liberally the new biochemical marker , serum B-naturetic peptide (BNP) to diagnose cardiac failure in lieu of basal auscultation.
- Advice cardiac resynchronisation therapy in all patients who are in class 4 cardiac failure with a wide qrs complex .
- As it is may be considered a crime to administer empirical heparin, do ventilation perfusion scan in all cases with suspected pulmonary embolism.
- Do serial CPK MB and troponin levels in all patients with well established STEMI .
- Open up all occluded coronary arteries irrespective of symptoms and muscle viability.
- Consider ablation of pulmonary veins as an initial strategy in patients with recurrent idiopathic AF. If it is not feasible atleast occlude their left atrial appendage with watch man device.
- Never tell your patients the truths about the diet , exercise & lifestyle modification (That can cure most of the early hypertension) . Instead encourage the use of newest ARBs or even try direct renin antoagonists to treat all those patients in stage 1 hypertension.
- Avoid regular heparin in acute coronary syndromes as it is a disgrace to use it in today’s world. Replace all prescription of heparin with enoxaparine or still better , fondaparinux whenever possible.
- Finally never discharge a heftily insured patient until he completes all the cardiology investigations that are available in your hospital .
Coming soon : 10 more ways to increase cost of cardiology care . . .beyond common man’s reach
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Posted in Cardiology - Clinical, Infrequently asked questions in cardiology (iFAQs), tagged acei, allhat, ARBS, diuretics, drsvenkatesan, hypertension, jnc7, lancet, loop of henle, reanl hypertension, salt sensitive, sodium, thiazide on September 8, 2008 |
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Diuretics are the most commonly prescribed anti hypertensive agents.Thiazide diuretics which was introduced many decades ago , lost popularity in recent years , again got a second life after the publication of ALLHAT trial recently. Now diuretics has become the the drug of first choice in almost any hypertension unless any specific contraindication.
The most commonly used thaizide is hydrochlorthiazide ,and chlorthalidone.The blood pressure reducing effect is so consistent and smooth , all the currently popular molecules like ACE inhibitors and ARBs come with a combination with thiazide. While every one is clear diuretics are effective anti hypertensive agent How it does is not clear.
How does a diuretic reduce blood pressure?
A. The exact mechanism is not clear. May not be uniformly effective in all patients with HT.
B . Salt sensitive HT respond well to diuretics.
C. Volume correction /free water clearance might be a factor
D. Direct effect on vascular smoth muscle documented.The sodium transporter is blocked and hence calcium : sodium exchange is prevented .This depletes intracellular calcium in vascular smooth muscle cells .Less calcium for actin myosin interaction and hence vasodilatation
E. Thiazides combine well with all other antihypertensive drugs (ACEI, ARB, Beata blockers, calcium blockers)
F. Loop diuretics like frusemide can never be a good antihypertensive agent.
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