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Text Q&A from Symposium

2016 GP Symposium.  Questions sent through by text on the day.

If statins work by stabilising the plaque, is a low dose of 10mgs atorvastatin better than nothing if patients are intolerant of higher doses even if their cholesterol does not drop by much?

Yes, 10mg is better than no statin. In fact 10mg will still give a fair reduction in the LDL cholesterol level, and will help the preventative process. In time, some patients find they can then tolerate a higher dose, as well.

What is the difference between Framingham risk assessment and Predict CVD risk assessment?

The predict risk assessment also adjusts for socioeconomic status, ethnicity and family history of premature cardiovascular disease. The predict is based on a contemporary NZ cohort (2002-2015) compared to the Framingham 1960-70s cohort 

At “Beyond Framingham: Risk Assessment workshop” it was mentioned that traditional Framingham risk assessment overestimate the risk by 5%. What about Predict?

Predict (based on Framingham risk factors) also appears to overestimate risk approximately 2 fold. However the strength of Predict is that cardiac events are being captured prospectively so the new Predict tool will estimate the risk more accurately at is derived directly from the current NZ cohort.

Obesity is a risk factor for CVD. Why is it not included in the predict for CVD risk assessment?

Excellent question: I suspect it is because the impact of obesity on cardiovascular health is only just being appreciated - the data on which the current risk tools are based likely did not have BMI as a variable that collected reliably and regularly: to my mind with obesity we are currently at a similar state to where smoking was in the 70s. I remember cigarette ads everywhere, even at the movies (admittedly not U movies as they were in the UK in the 70s) with parents happily smoking in the movies - the medical fraternity knew that smoking caused significant morbidity and mortality, but this was not acknowledged by policy makers for 10-20 years - even now there is still a battle e.g. plain cigarette packing in Western countries and aggressive marketing in the non-Western ones. As policy makers recognise the impact that obesity will have on future health expenditure things will change and this is one area change may occur.

At any point is it safe to stop triple therapy. E.g. 3 years post they have done lifestyle changes and no further chest pains or event, can they consider stopping or reducing triple therapy?

Yes, absolutely. The main benefit for triple therapy (aspirin, clopidogrel, warfarin) is in the first year following coronary intervention, especially for ACS. It would be highly unusual for us to continue it for longer than a year because the the risk of bleeding outweights the benefit.

The usual practice in Auckland is to give triple therapy for a period of time (1-6 months) then cut back to clopidogrel and warfarin. If they remain stable then many of us will just leave them on warfarin from 12 months on. We may choose to treat them long term with aspirin/warfarin, eg: symptomatic PVD (including carotid/cerebrovascular), recurrent angina/MI with un-revascularizable coronary anatomy, etc. We would guide you on this though.

What should we recommend between butter or margarine?  And often asked best oil to use? They can’t all afford olive oil.  What do you think of the 5 plus 2 diet?  Fad or fantastic?

Simple and sensible messages are the key. Patients should eat a diet with plenty of fresh fruit/vegetables, limited starch/refined carbs/sugar, lean meat, exercise regularly, and take their prescribed medications. For cooking I recommend using sparing quantities of unsaturated vegetable oil. Grilling, baking, steaming are great non-oil ways to cook food. There are other tasty spreads apart from butter/marg, eg: hummus.

The main issue is portioning. In the western world it’s very easy to eat to excess, and most weight control programmes emphasize correct portioning as well as types of food. I think there is far more benefit to be gained from addressing overconsumption of bread/pasta, takeaways, baked goods, junk food, sugary drinks, alcohol, high fat dairy products etc.

The 5+2 diet does lead to weight loss, but like many fad diets the loss is not sustained.

We need to acknowledge that many people will continue to struggle with diet so long as there is a large abundance of cheap, convenient, tasty, calorie dense, nutritionally poor foodstuffs out there that are heavily marketed and generate large profits for companies that enable them to influence politicians. As doctors we need to support political initiatives to address this imbalance in the food supply.

For AF does weight loss advice apply to patient with BMI between 20 to 27?

No, there is has been no study of weight management in patients with a BMI <27. Once this has been achieve other risk factors should be managed (hypertension management, alcohol intake, exercise regimen, and possibly sleep apnoea treatment, although less likely required at this weight).

For newly diagnosed AF (not necessarily recent onset) when do you opt for rhythm control whether DCCV or with medications. When for rate control?

This was the subject of my talk last year. With the exception of elderly patients, or those with significant co-morbidities, I think we should at least consider 1 attempt at cardioversion for a first persistent episode of atrial fibrillation. In general rhythm control should be considered for paroxysmal atrial fibrillation, new onset atrial fibrillation with heart failure, those with significant symptoms, and those who have “failed” rate control, i.e. significantly symptomatic patients despite rate control, or those who can’t be adequately rate controlled. Below is an appropriate flow diagram published last week in a review paper in Lancet.

What do you think about duromine for weight loss?

This is not a drug I have experience of. I understand it works by having an amphetatine like effect, increasing metabolic rate / suppressing appetite and bringing about weight loss in this fashion. It can have negative impact on the cardiovascular system, especially in combination with fenfluramine, causing valvular damage. Personally I favour a non-pharmacological approach, ultimately obesity is not a condition with a quick fix 

Where do we get those tables for classification according to ethnicity?

Most of my information relevant to our population came from the Health of the Nation 2014/15 : follow the link : http://www.health.govt.nz/publication/understanding-excess-body-weight-new-zealand-health-survey

How do we deal with the lymphatic oedema caused by obesity?

The first thing is to be sure that the JVP is normal - this can be hard in an obese patient - sometimes can only see with a patient sitting up. Pulsating earlobes can be a marker for a very high JVP

If the JVP is normal then use of low dose diuretic may help, but dose should not be progressively escalated - this can just result in intravascular volume depletion. These patients are not truly hypervolaemic, just have fluid in the wrong space for a mechanical / drainage reason

Treatment is otherwise targeted at trying to alleviate the oedema to ease “heavy legs” and help maintain skin integrity - chronic oedema is harmful to skin health causing skin fragility, dryness and pigmentation with an increased risk of ulceration / poor healing after minor trauma - measures that can help include leg elevation / leg massage and graded compression stockings, of course along with weight loss and regular exercise to help get the calf muscle pump going.

Can Tim comment on the new trend to eat more fat rich food instead of more sugar?

This really lies in the field of a dietician : I am not a great believer in fad diets. Moderation is the key, eating a healthy balance of each food group. If fat intake is higher then should avoid transfats - most governments have taking active steps to control these, along with having polyunsaturated fat rather than saturated fat - eg Mediterranean diet - 1 trial that showed a benefit from this had patients consuming a litre of olive oil a week on top of their usual intake! Whichever diet is followed it must be sustainable, not just for a months or two, but for life - hence a well-rounded and balanced one that is palatable will generally work best

The high recurrence of arf is not given prophylactic antibiotics, is this due to poverty and overcrowding or is there a propensity for some to get arf ? In other words, has the first attack of ARF uncovered those patients who for some reason at higher risk of arf ?

Only 1% of GAS + pharyngitis is complicated by ARF. Once you have had ARF your risk of recurrence increases 25 - 50% over baseline risk. These both suggest a biologic vulnerability. We are currently conducting genetic studies to unravel this conundrum.

I do see lots of paediatric patients with left sided heart murmurs. How do I decide which ones need further referral?.

Innocent flow murmurs are very common in preschool children. They are typically heard at LLSE in supine position; Grade 1-3/6 in intensity; Ejection (crescendo/ decrescendo) in character; Made louder by fever anaemia or anxiety; Quieter when sitting up or standing.

I recommend referral of murmurs if:

  • Heard for the first time before age of 1 year or after 4 years (Maaori or Pacific child
  • Murmur heard in back or axilla
  • Cardiac symptoms or exercise intolerance
  • Weak femoral pulses 


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