Difficult to Manage Hypertension

I saw a patient in the Ambulatory GIM clinic referred for hypertension. He had a history of difficult to manage hypertension and was currently taking 5 agents to lower blood pressure: ACE inhibitor, calcium channel blocker, beta-blocker, loop diuretic, and a nitroglycerin patch. Despite these, he was referred to the ED after a family doctor found an office blood pressure over 200/110. Thankfully he was asymptomatic and investigations showed no evidence of end organ damage. In the office his blood pressure was in the normal range. However, we were still concerned about refractory hypertension. My preceptor helped me work through a differential diagnosis for secondary causes hypertension. We ordered plasma metanephrines and a renin-aldosterone ratio to assess for pheochromocytoma and Conn's syndrome, respectively. We ordered an abdominal ultrasound to assess for renal artery stenosis. On physical exam we did not detect any signs of Cushing syndrome and so thought 24h urine cortisol wasn't necessary. We also thought about whether the patient would benefit from intensive blood pressure control. The patient did not have a history of diabetes or stroke and so might benefit from a blood pressure target under 120 systolic evidenced by the SPRINT trial. This was a great educational experience allowing me to think through refractory hypertension and it also allowed us to explore some emerging evidence on more aggressive blood pressure targets.

- MH

Physical Exam to Detect Anemia

I was in ambulatory GIM clinic seeing a patient referred for chronic anemia. She had been worked up over many years, including a bone marrow aspirate years prior which confirmed a diagnosis of iron deficiency anemia. She had been on iron supplementation and her hemoglobin improved for a time. However, recently it had dropped again and this was why she was representing. The patient's chief symptom was fatigue. I spent a lot of time working through the lab tests and identified a normocytic anemia. I built a differential diagnosis and presented this to my preceptor. During the presentation, I was asked about any physical exam findings for anemia. I realized I hadn't focused on this, and other than a vague idea about skin pallor didn't have a good approach to this aspect of the presentation of anemia. I was thankful to have my preceptor demonstrate the different physical exam findings with me and the patient. I learned that the best place to look for pallor is the conjunctiva, nail beds, and palms. My preceptor looked at the nail beds and explained that thinning, flattening, and spooning of the nails can occur with iron deficiency anemia. Other findings more specific to iron deficiency anemia include: glossitis, and angular stomatitis. This was an excellent learning experience. I realized I had focused too heavily on the lab tests in my workup of anemia. The physical exam can provide useful clues as to severity and chronicity of the problem. I was thankful for bedside teaching that helped me build my approach and competence for recognizing signs of anemia and iron deficiency on physical exam.

- MH

Knowledge translation and patient engagement

In Cardiology clinic last week, I met a man who was being followed post-STEMI and angioplasty, with his last event occurring in 2017. He was feeling well, and happy with his course over the past year and a half - following this, the question du jour became what to do with his dual antiplatelet therapy (DAPT). 

On review with my staff, we discussed the most recent set of recommendations from the Canadian Cardiovascular Society (https://www.onlinecjc.ca/article/S0828-282X(17)31221-7/pdf) for post-PCI DAPT, and felt satisfied with this patient's course thus far, particularly his absence of ischemic or bleeding events, and ability to tolerate his medications. We now asked ourselves, what was the utility in continuing his Clopidogrel for another 6 months? Another year?

There isn't a hard and fast answer to this question, but there are tools that help with decision-making around DAPT, to which my staff introduced me that afternoon.

The DAPT Online Calculator (http://tools.acc.org/DAPTriskapp/#!/content/calculator/), hosted by the American College of Cardiology, can be used to help guide conversations around DAPT, specifically as it relates to ischemic and bleeding risks, based on a patient's unique risk profile.

It also includes a section that specifically compares the rates of events upon cessation of therapy at 12 months (generally the minimum duration of treatment post-PCI) vs. continued treatment.

Of note, this calculator is intended for use in patients who had been on 12 months of DAPT therapy, without any ischemic or hemorrhagic events during the treatment period - importantly, this reflected the patient we were seeing in clinic that afternoon.

There are a few advantages to using this calculator as an adjunct to assessment and planning. For one, it helps guide trainees and staff through conversations about relevant cardiovascular risk factors, DAPT treatment complications, and treatment utility, which serves as a great learning tool.

It also produces data in a very clear and simple fashion, serving as a bridge to facilitate more open and accessible conversations between the care team and the patient themselves; when taken advantage of, this can promote patient-centred care. 

I look forward to having more opportunities on the Cardiology service to further develop my own knowledge around treatment and risk prevention in ACS, and capitalize on emerging tools (like this calculator) to help facilitate clear communication and support patient engagement in my practice.