in public hospitals like HKL surgeons and consultants are still being called Mr...

if he had least spend one day off to day a full medical check up once a year when he started working he could be still very well alive. kesian.

for public uni yes why not.

yeah but if the TGL levels are really high fibrates should be started along with statins.

yes but this was a discharge script. the patient might have already been started on initial therapy during admission. no? furthermore it is unclear on how long has the patient been admitted and what other drugs has the patient been taking along with his other test results. IMO besides the duplication of aspirin, its hard to justify whether the script is accurate or not based on present data.

gemfibrozil is to lower TGL levels, beta blockers work on the heart. both drugs work differently and have different mechanisms and different outcomes. u only start statins if patient has a previous cardio/stroke event. if levels all ok then no issue la. but having said that if you get admitted probably got problem liao.

This post has been edited by zstan: Dec 17 2012, 07:23 PM

ah my bad then. didn't really check the DOA. so yeah, the fibrates shouldn't be prescribed together with statins. yeap the statin dose is quite low and not maxed out yet. my mistake on part 4. should be referring to high risk patients.

yeah cheaper. statins mostly differ by their potency.

yeah statins are usually prescribed if the patients has diabetes. hmm not so sure if that's the correct practice though if the consultant does not bother about the lipid profile.

rosuvastatin has the highest incidence of liver and muscle side effects so it is generally avoided.

fibrates is more related to risk reduction in diabates compared to a cardiovascular event. its usage is more limited to reduce TGL levels and that's about it

plavix is there to prevent clot formation. working together with aspirin.

from lectures i would guess because its the most expensive.....? anyway, its just more incidence compared to other statins doesn't mean its bad otherwise it would be pulled out of the market.

its from my lectures made by practitioners. guess in practice its a different story.

both drugs causes hyperglyceamia. which may lead to diabetes if not properly monitored.

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

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

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

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

vasoconstriction.. hypertrophy of the heart... renin release which triggers aldosterone release... Na retention..increase fluid retention.. BP raised..

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Added on December 20, 2012, 12:02 amyeah CCB will also cause peripheral oedema which is very hard to get rid off. so its best to avoid.

This post has been edited by zstan: Dec 20 2012, 12:02 AM

All of these happen concurrently when angiotensin 2 binds to the AT1 receptors. There's no dominant process and it is a positive feedback mechanis. However if you are talking about short term and long term eeffects of excess angiotensin 2 circulating ijbthe body then vasoconstriction and bp increase takes place first and hypertrophy comes later at a slower rate. Hence if you dont treat it your condition will get more and more worse. Which brings back to improving survival rate and qualityof life. Hope I answered your question.

This post has been edited by zstan: Dec 20 2012, 12:53 PM

the first choice is always ACEI due to the cost, sartans are still relatively new are much pricier and are only used when ACEI are not effective (in the private settings it may be another story though). but both should never be used together.

technically ARBs are more effective as it binds directly to the receptors hence angiotensin 2 have no where to bind and get degraded. In the case of enzyme inhibition there's bound to be some ACE escaping the effects of ACEI. but in real life scenarios it may differ.

This post has been edited by zstan: Dec 20 2012, 04:43 PM

its really not recommended... there's always other choices of BP lowering drugs.. combination of these 2 will result in declining renal function. the electrolyte imbalance will also be more severe if combined.

http://www.jfponline.com/pages.asp?aid=7183

well if you want to opt for 'smaller' hospitals you can always apply places like pahang, kelantan, terengganu, perak etc.