B blocker is contraindicated in both coad and asthma as it causes bronchial constriction. I have not seen patients with coad or asthma being started on b blocker. Perhaps the patients u have seen are having cardiac asthma?

In theory, that only applies to non-selective BBs right? How atenolol?

The cardio selective bb loses its receptor selectivity at higher dosage.

http://en.m.wikipedia.org/wiki/Beta_blocker

Read under the section adverse effects.

This post has been edited by hypermax: Dec 18 2012, 10:11 AM

fibrates are not like statins which can give you other benefits, their only role is to lower TGL. fish oil with omega 3 and 6 seems to be a more popular choice now.

beta blocker is also contraindicated in people with vascular diseases. but the benefits still outweighs the risk.

at the end of the day, like onelove89 mentioned, is to see whether the benefits outweigh the risk or not. even in an asthmatic patient, if the patient needs a b-blocker to survive it has to be given and the asthma is being contained in some other ways (if the patient suffers an attack). and a drug being selective doesn't mean 100% of the drug particles are selective. as hypermax pointed out, as the dosage increases there will be more circulating drugs in the system and just 1% of the stray particles maybe enough to trigger and attack. having said that some asthmatic patients may also not react to the beta blocker. so the best way is to monitor the patient and prescribe accordingly and start with small doses.


This post has been edited by zstan: Dec 18 2012, 02:00 PM

we should really have more of these discussions.

OK, again. Pls spot the mistake in this discharge note.

Can only read Humulin, Furosemide, Felodipine....maybe Enalapril, Aspirin and ... not so sure about the last one.

Patient given diuretics despite being DM n on insulin treatment?

Last one is simvastatin. ccb given with ccf? Wanna kill the patient mer

Good one.

The list of meds were prescribed by a senior MO graduated from a renown university in developed country. From the same hospital as the previous case.

That's why I am against judging a doctor purely based on where he graduated from.

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Added on December 18, 2012, 11:40 pmFurosemide is needed in this case as the patient has CCF. This is again a case of benefits outweigh the risks.

This post has been edited by hypermax: Dec 18 2012, 11:40 PM

Tripple whammy right there as well?

Also this article may be interest for you guys.

http://www.ncbi.nlm.nih.gov/pubmed/9264493

This post has been edited by D_s_X: Dec 19 2012, 12:10 AM

firstly the article compares the drug against a placebo, which is pointless in this time and age. of course the drugs performs better than a placebo.

'Of the 450 patients, 55% were identified as having coronary artery disease as the cause of their heart failure, and the remaining 45% were classified as having a nonischemic cause.'

in this case actually only about 45% of the patients are more prone to heart failure worsening by the CCB IMO. in people with CAD your heart may be still be fine (valves and walls still normal).

also there isn't any confidence interval for the decrease in blood pressure hence it may not be clinically significant although its statistically significant. mortality rates for both are the same as well.

anyway the discussion and conclusion pretty much sums it up:

"Despite these modestly favorable hemodynamic and hormonal effects, however, felodipine ER therapy was not associated with clear-cut short-term or long-term clinical benefit.

This study, therefore, does not support the concept that a dihydropyridine calcium antagonist can strikingly augment the favorable clinical response to ACE inhibitors in heart failure. Nonetheless, the data suggest that felodipine ER can be used safely in patients with heart failure if used for another indication. "

so maybe the MO is treating the patient for hypertension? sorry can't really read the abbreviations. but this means that Felodipine is not contraindicated with CCF and the script is accurate.

This post has been edited by zstan: Dec 19 2012, 12:37 AM

1. This patient has both hypertension and CCF, thus felodipine should not be used as first line therapy. In the above case, dose of enalapril is still not optimized.

2. Beta blocker could be added for this case in place of felodipine. Beta blocker is known to be beneficial in patients with heart failure, and it treats hypertension as well.

3. Calcium channel blocker is best avoided in systolic heart failure, but can be used safely in diastolic heart failure. Both conditions can only be distinguished with echocardiography. However, both conditions often coexist in clinical practice. Echo was not done in the above case.

4. Another study done on felodipine in heart failure
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1277290/


It is really good to see healthy discussions going on. Keep up the good work guys.

This post has been edited by hypermax: Dec 19 2012, 06:58 AM

Agreed that CCB should be changed to B-blocker. Here we use metoprolol, and some heart function clinics (run by heart failure specialist, ie cardiologist who did fellowships in HF) uses atenolol, not sure why.

It is quite interesting to know that in Malaysia we can diagnose "CCF" without a documented Echo. I know it's a clinical diagnosis but still, wouldn't you want to know whether you have missed any important information, ie Pulmonary HTN, LV RV size EF etc.

How's CCF generally diagnosed in Malaysia anyway?

CXR, HT, maybe ankle/sacral edema?

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Added on December 19, 2012, 8:10 amNice. As hypermax mentioned, MOs can only prescribe lovostatin..so how did this happen?

Ah.. Thanks. Learn something new everyday

At least the doc has a decent handwriting

This post has been edited by Syd G: Dec 19 2012, 08:10 AM

The person who prescribed the meds in this case is a senior MO (UD48). In district hospital, senior MOs sometimes function as specialist in terms of drug prescription.

I see your point, but maybe it's just one of those things that just works for the patient.

I have no idea about diagnosis of CCF in Malaysia, but I do know theres Framingham's Citreria (not like I remember the citrerias)

EDIT: just added the criteria for completeness after searching

Major criteria:

Cardiomegaly on chest radiography
S3 gallop (a third heart sound)
Acute pulmonary edema
Paroxysmal nocturnal dyspnea
Crackles on lung auscultation
Central venous pressure of more than 16 cm H2O at the right atrium
Jugular vein distension
Positive abdominojugular test
Weight loss of more than 4.5 kg in 5 days in response to treatment

Minor criteria:

Tachycardia of more than 120 beats per minute
Nocturnal cough
Dyspnea on ordinary exertion
Pleural effusion
Decrease in vital capacity by one third from maximum recorded
Hepatomegaly
Bilateral ankle edema

2 major criteria OR 1 major and 2 minor criteria.

Also, does anyone know what else they look for in echos for CCF besides Ejection fraction (Systolic failure) and LV function (both systolic and diastolic failure)?

Is it a diagnosis by a specialist only?

This post has been edited by D_s_X: Dec 19 2012, 10:26 AM

beta blocker should not be used here because the patient has diabetes..though this can improvised...how was the patient's kidney's condition? considering patient has DM the kidney may not be fully functional as well. ivabradine could be used though (not sure whether district hospital has this drug). enalapril is already at the 10mg target to manage aldosterone levels as well as stabilising the bp. the diuretics is also helpful against the patient's hypertension along with resolving the oedema so there are 3 drugs for hypertension now. without echo its really hard to tell how bad has the heart failed and how bad will the CCB affect the heart(class 1/2/3/4 using NYHA classification?)

also that study was done in 1987, not very sure whether the same circumstances applies 25 years later.

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Added on December 19, 2012, 2:30 pmyou could also look for hypertrophy of the atrium or ventricles or whether are the walls dilated (dilated cardiomyopathy)

This post has been edited by zstan: Dec 19 2012, 02:42 PM

Wall thickness, and ventricular size/mass too I think. but mainly EF and LV function and determining whether it's sys or dias.

I know there's the boston criteria too.

http://www.aafp.org/afp/2000/0301/p1319.html

think both criteria are pretty similar in terms of sensitivity and specificity.

The patient's functional capacity (CCF re NYHA classification) is much more important than the Echo itself IMO. Some people function very well with relatively low EF.



Does it really matter that much if it's systolic or diastolic failure in practice? Any practictioners out there care to enlighten me?

http://eurheartj.oxfordjournals.org/conten...pl_D/2.abstract

Summary:

Systolic failure: ACEI, Digitalis, Diuretics
Diastolic Failure: ACEI, BB, CCB, Diuretics +- Digitalis (in AF).

I don't think many people are put on Digitalis anyway unless they have AF due to risk of toxicity.

1. Beta blocker is not recommended in DM patients, but it is not absolutely contraindicated. Compare to CCB in heart failure, it is relatively safer.

2. Low dose Beta blocker is generally used in HF. So even DM patients with HF are well tolerated towards BB.

3. There are many studies with conflicting views on the usage of CCB in HF. But in general, CCB is best avoided in diastolic HF (a strong physiology knowledge will tell you why)

4. Enalapril can be used as high as 20mg BD in HF

5. Kidney functions are normal in this case.

In practice, both systolic and diastolic HF often coexist (according to my consultant, more reference needed). Thus CCB shouldn't be used as first line.

This post has been edited by hypermax: Dec 19 2012, 07:08 PM