Beta-blockers in asthma | Cardiology | 08-2010
There are a series of articles suggesting that in patients without irreversible asthma such as COPD, beta-blockers can be utilized. But it may prove a challenge to sort out how ...
Digoxin dosing | Cardiology | 04-2010
The indications for digoxin in the elderly include the treatment of systolic heart failure when diuretics, ACE inhibitors and beta blockers are insufficient and sometimes to help with rate control ...
Titrating beta-blockers? Follow your heart | Cardiology | 03-2010
When using a beta-blocker, the end-point should be the target heart rate, rather than the target dose. A meta-analysis of 23 RCTs was done to look into this issue of ...
ACE plus ARB for rising ACR? | Cardiology | 01-2010
I ve never had a patient come back and say to me, Doctor, I feel so much better now that I m putting out less albumin or protein in my ...
Thoughts on thiazolidinediones | Endocrinology | 09-2008
TZDs are still a useful option for controlling hypoglycemia, but their use must be tailored to the individual. TZDs shouldn't be used in patients with any kind of heart failure ...
Balancing diuretics to treat pleural effusion | Respirology, Cardiology | 03-2008
Pleural effusion alone is not a common sign in cor pulmonale, also known as right-sided heart failure from lung disease. If that's the only presenting feature, other diagnoses should be ...
Balancing diuretics to treat pleural effusion | Respirology, Cardiology | 03-2008
Chronic elevation of right atrial pressure or pulmonary arterial pressure, or both, isn't a cause of pleural effusion if it occurs in isolation, according to at least one study Chest ...
Preventing hyponatremia in nursing homes | Geriatrics | 02-2008
Although hyponatremia is usually defined as a plasma sodium 135 mm L, the frail elderly, particularly those with cognitive vulnerability, may show increased confusion when sodium levels fall under 130. ...
Best test for diabetic kidney | Nephrology | 07-2007
The albumin creatinine ratio calculated from the first morning urine sample correlates well with respect to high sensitivity and specificity with those in 24-hr urine samples, save for a few ...
How to quit beta-blockers | Cardiology | 06-2007
As you're well aware, the Canadian Hypertension Society no longer recommends beta-blockers as first-line therapy in the management of uncomplicated hypertension in individuals aged 60 or older. These drugs are ...
LVAD: new device for treating heart failure | Cardiology | 05-2007
You've asked some good questions. However, LVADs are not used at our clinic at McMaster University. Currently in Canada, there are a limited number of transplant centres and these devices ...
When should we measure B-type natriuretic peptide? | Cardiology | 04-2007
I've had the pleasure of working with BNP in a large Canadian trial that was looking at its value in the diagnosis of patients presenting to the emergency department with ...
Treating diabetes and hyperkalemia | Endocrinology | 12-2006
Hyperkalemia in a diabetic patient is usually related to hyporeninemic hypoaldosteronism. Fludrocortisone at 0.1 mg day may be used to control the high potassium level if it persists. In cases ...
Renal disorders: can NSAIDs be prescribed? | Nephrology | 06-2006
Selective NSAIDs, such as cyclooxygenase-2 COX-2 inhibitors, and non-selective agents are commonly used for managing pain. The enzyme COX-2 is constitutively expressed in the kidney and is highly regulated in ...
Is vitamin E in cosmetics a problem? | Dermatology | 05-2006
Vitamin E is a popular additive found in cosmetic and pharmaceutical products. Its claim to fame is its role as an antioxidant. There was once a time when its presence ...
What workup is needed for pedal edema? | Cardiology | 04-2006
If I assume that the pedal edema is bilateral, pitting and of recent onset, I think you want to rule out congestive heart failure. An echocardiogram would be useful. Also, ...
Do beta-blockers worsen ED? | Cardiology | 04-2006
Erectile dysfunction is common in patients with vascular disease, and it's always a challenge to sort out whether the medication is a cause or an aggravating factor. The best randomized ...
What workup is needed for pedal edema? | Nephrology | 04-2006
There are various causes of pedal edema. First and foremost, a detailed history and physical examination is the mainstay to tailor further investigations. The focus of the exam should be ...
Atrial fib: should ASA be added to warfarin? | Cardiology | 03-2006
Atrial fibrillation is the most frequent arrhythmia of the elderly, occurring in more than 10 of people over the age of 70 years. As the Canadian population continues to age, ...
When should patients forego flying? | Cardiology | 03-2006
Air travel poses stressors on a patient, from the general such as moving through crowded airports, to the specific related to aircraft environment. Most importantly, flight entails reduced barometric pressure, ...
COPD: when to add ofloxacin to ventilator | Respirology | 03-2006
This is a tough question. When patients have a life-threatening disease, i.e. one that requires mechanical ventilation, say COPD with chronic bronchitis, we would likely cover them with antibiotics, usually ...
When should patients forego flying? | Respirology | 03-2006
Absolute contraindications to individuals flying would be any unstable disease, e.g. unstable angina, congestive heart failure, uncontrolled asthma, etc. amp lt br amp gt amp lt br amp gt A ...
Sparing the side effects of spironolactone | Cardiology | 01-2006
For patients with New York Heart Association NYHA Class III or IV heart failure, the Randomized Aldactone Evaluation Study RALES has reliably shown a mortality benefit when using spironolactone in ...
Do bronchodilators work for CHF? | Geriatrics | 01-2006
Classically, elderly patients with pulmonary edema secondary to severe heart failure can present with cardiac asthma and considerable wheezing. This isn't true asthma and I don't think there's any evidence ...
Do bronchodilators work for CHF? | Respirology | 01-2006
To my knowledge, there are no trials in this setting. We do appreciate, however, that individuals in heart failure can have increased bronchial hyper-reactivity, with bronchospasm and bronchial edema that ...
Hacking away at a dry cough | Respirology | 12-2005
It's unusual to have a non-productive cough with bronchiectasis unless it's in the upper lobes. You should look for other causes, such as post-nasal drip, reflux esophagitis and reversible airflow ...
Watch for warfarin evidence | Cardiology | 11-2005
The most important trial in this area is the Warfarin and Antiplatelet Therapy in Heart Failure trial WATCH , which demonstrated no significant differences between warfarin, ASA and clopidogrel in ...
Effect of NSAIDs and COX-2s on BP | Cardiology | 09-2005
One of my medical students and I are presently working on a review regarding COX inhibition and vascular risk, due to come out shortly. NSAIDs and COX-2 inhibitors relieve pain ...
Count on stroke prevention | Hematology | 06-2005
I assume your question refers to anticoagulation in patients with atrial fibrillation AF . The likelihood of stroke in individuals with AF who don't receive warfarin varies greatly, depending on ...
Confusion reigns over HOPE in EUROPA | CArdiology | 05-2005
Unfortunately, despite keeping up to date, I would consider the evidence from large clinical trials conflicting. My take-home message is to treat blood pressure aggressively, and for many patients, that ...
Clopidogrel with ASA: bleeding vs benefits | Cardiology | 02-2005
You raise a number of very interesting points. First, let me review the current evidence amp lt br amp gt amp amp 149 the Clopidogrel in Unstable angina to prevent ...
Clozapine: at the heart of side effects | Psychiatry | 01-2005
Clozapine can produce a dose-related postural hypotension and related tachycardia that are most pronounced at higher doses. This may occur after the first use, get worse for a few days ...
Simply red over positive D-dimer | Hematology | 11-2004
There's no such a thing as a false positive D-dimer assay. If you believe that D-dimer is specific for venous thromboembolism VTE , however, then there are numerous conditions that ...
Will salbutamol worsen angina? | Respirology | 11-2004
It's necessary to quickly assess the severity of both the angina and airflow obstruction with an electrocardiogram, vitals, tests for accessory muscle use, paradoxical breathing, oxygen saturation, etc. If the ...
Can ACEs or ARBs trigger angioedema? | Cardiology | 09-2004
Angioedema is a well-known side effect of ACE inhibitors, with a reported incidence of 0.1-0.2 . Research shows that 10-25 of presentations of this disease can be ascribed to this ...
Novel tests using BNP | Cardiology | 08-2004
BNP was first isolated in the pig brain. In humans, it's found predominantly in the heart ventricle and rises in response to increased pressure, such as that seen in congestive ...
Z-Z-Z-Zs and central sleep apnea | Neurology | 08-2004
One of the most common forms of adult breathing problems in sleep remains obstructive sleep apnea. To treat this, weight loss, CPAP, upper airway surgery and oral appliances can provide ...
Novel tests using BNP | Respirology | 08-2004
We've just begun to use BNP and it's not always available in most clinical institutions. Preliminary data indicate that high levels suggest congestive heart failure. So this test may be ...
Might metformin matter? | Cardiology | 07-2004
This requires clinical judgement, as metformin is an extremely important agent for blood sugar management, especially in overweight diabetics. Patients with renal insufficiency and or liver dysfunction are prone to ...
Might metformin matter? | Endocrinology | 07-2004
Heart failure can lead to reduced perfusion and the risk of lactic acidosis, and the concern is that metformin could contribute to its development in susceptible individuals. The Canadian Diabetes ...
Can ramipril reduce vascular complications? | Cardiology | 05-2004
HOPE, a major study from 19 countries, evaluated 9,541 patients over age 55 with existing cardiovascular disease or with diabetes and an additional cardiac risk factor such as hyperlipidemia and ...
Insulin options for greater glycemic control | Endocrinology | 05-2004
Pre-mixed insulin is convenient but inflexible. The key to good glycemic control is the ability of the patient to adjust his or her insulin depending on meals and activity. In ...
Newborn murmurs: refer to cardiologist? | Dermatology | 04-2004
A systolic murmur in a well, thriving infant can often be managed with observation and careful follow-up. As you mentioned, many of these murmurs will disappear. Most are physiologic and ...
Newborn murmurs: refer to cardiologist? | Pediatrics | 04-2004
A systolic murmur in a well, thriving infant can often be managed with observation and careful follow-up. As you mentioned, many of these murmurs will disappear. Most are physiologic and ...
Prostate Tx with alpha-blockers and cardiac effects | Cardiology | 03-2004
As you know, the ALLHAT Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial study was stopped prematurely because the alpha-blocker doxazosin was found to be less effective than the ...
Managing low hyponatremia in CHF patients | Cardiology | 03-2004
Hyponatremia is a common problem in advanced heart failure, and is often caused by volume contraction. Patients often require hospitalization to adjust medication needs, which may include withholding diuretics for ...
How to deal with ACE inhibitor cough | Respirology | 02-2004
Stopping it is the best choice, as it can cause increased bronchial hyperreactivity. If it needs to be replaced with a similar drug, e.g. to treat congestive heart failure CHF ...
How are D-dimer tests interpreted? | Hematology | 09-2003
I don't think you really want to know all the conditions giving false-positive or false-negative D-dimer results. You're probably more interested in which conditions other than venous thromboembolism VTE can ...
Beta-blockers: still okay for elderly hypertensives? | Cardiology | 05-2003
The Canadian consensus guidelines on hypertension suggest that patients above age 60 shouldn t be considered for beta-blockers as first-line therapy. Keep in mind, however, that these recommendations were based ...
MRI's potential in thoracic imaging | Imaging | 04-2003
MRI has dramatically altered the practice of medical imaging, particularly in the areas of neurology and orthopedics, but hasn't affected thoracic imaging much. Part of the problem is that air-filled ...
Which beta-blocker is best | Cardiology | 03-2003
Beta-blockers lower blood pressure, are excellent antianginal agents, are invaluable in the management of congestive heart failure CHF , and are protective following an MI. Bisoprolol is the latest beta-blocker ...
Tips on grading COPD severity | Respirology | 03-2003
Severity of COPD is best graded based on simple spirometry and the extent of dyspnea. Spirometry consists of performing the forced expired volume in one second FEV1 and relating this ...
O2 saturation monitoring in COPD | Respirology | 02-2003
Although spirometry is most useful in diagnosing and following the progress of COPD, monitoring oxygen saturation helps to identify individuals who may be candidates for long-term home oxygen. Saturations below ...
Wise use of beta-blockers and CCBs for angina | Cardiology | 01-2003
We currently have three effective drugs to treat angina pectoris CCBs, beta-blockers and nitrates. Beta-blockers are the first-line therapy in the treatment of angina because of vascular protection and costs. ...
Chest pain + positive D-dimer = PE? | Hematology | 11-2002
I should first comment that the presence of chest pain and positive SimpliRED D-dimer isn't necessarily indicative of PE. Several reports have shown that if there's a low clinical probability ...
Smoker's cough: what to look for | Respirology | 11-2002
The first step is a directed history and physical, looking for possible causes of hypersensitivity pneumonitis, such as humidifier lung and bird fancier's disease other diseases, such as obesity, history ...
CAN PIOGLITAZONE HELP IN TYPE 1 DIABETES? | Endocrinology | 09-2002
The situation you've described can be very challenging to manage, and the options may be limited by what the patient is able to do herself, what resources are available in ...
Choosing ACE inhibitors in renal disease | Nephrology | 09-2002
Fosinopril is a long-acting prodrug that differs from other class II ACE inhibitors because of its dual route of excretion, hepatic and renal. This means there's less accumulation of the ...
NSAIDS AND ACE INHIBITORS: AN UNEASY MIX | Cardiology | 07-2002
NSAIDs make the management of hypertension more difficult and can aggravate the tendency towards congestive heart failure CHF in some patients. Be sure to keep an eye on renal function ...
EASING CHF PATIENTS ONTO BETA-BLOCKERS | Cardiology | 07-2002
Beta-blockers are invaluable in the management of CHF. A series of randomized, controlled trials has demonstrated that, over time, beta-blockers extend life and improve quality of life, provided that the ...
Investigating GFR drop after ACE inhibitor | Nephrology | 05-2002
Angiotensin II exerts a vasoconstrictive effect on both afferent and efferent arterioles, but it's preferential on the efferent side. Not only in renal artery stenosis either bilateral or in a ...
Creatinine monitoring for ACE inhibitors | Cardiology | 04-2002
Serum creatinine levels can rise in patients on ACE inhibitors and may reflect a drop in intraglomerular pressure, which is actually a benefit of therapy with these drugs. Marked increases, ...
CCBs: THE MORE THE BETTER? | Cardiology | 03-2002
As you know, the management of hypertension is becoming increasingly more complex. It's now apparent that only about one-third of patients with hypertension can be controlled using single-drug therapy. Most ...
ARBS INSTEAD OF ACE INHIBITORS FOR CHF? | Cardiology | 01-2002
Patients who can't take ACE inhibitors could certainly be considered for ARBs. Most recently, the Valsartan Heart Failure Trial Val-HeFT has demonstrated that adding ARBs to ACE inhibitors or other ...
CAN METFORMIN HELP TYPE 1 DIABETES? | Endocrinology | 12-2001
Some very small studies from the 1980s address this issue, and the consensus seems to be that metformin is indeed beneficial in managing Type 1 diabetes, especially in obese patients. ...
A PLACE FOR CCBs | Cardiology | 07-2001
Long-acting nifedipine is an excellent antihypertensive agent and is useful in preventing angina. As a class, however, calcium channel blockers CCBs , including nifedipine, are more costly than other options, ...
WARFARIN VS HEPARIN FOR ATRIAL FIBRILLATION | Cardiology | 05-2001
Patients who are in atrial fibrillation have a yearly stroke rate of about 5 . Low-risk patients are under age 50 with no other risk factors like hypertension, diabetes or ...
ROSIGLITAZONE FOR DIABETES? | Endocrinology | 05-2001
I'm aware of two studies comparing the combination of insulin and rosiglitazone with insulin and placebo in double-blind studies. Over 50 of patients receiving rosiglitazone 8 mg daily plus insulin ...
WHY THE PAINFULLY SWOLLEN LEG? | Cardiology | 08-2000
It's difficult to make recommendations without seeing the patient, but a grossly edematous and painful single leg isn't normal. You've looked for deep vein thrombosis DVT with venography and ultrasound, ...
CHEST PAIN: ORGANIZING THE DIAGNOSTIC WORK-UP | Cardiology | 08-2000
Once you've stabilized a patient with chest pain, having gone through the ABCs airway, breathing and circulation , then it's reasonable to proceed to the diagnostic work-up. First, make sure ...
CoQ10 DROP FROM STATINS: CAUSE FOR CONCERN? | Cardiology | 05-2000
CoQ10 is now one of the amp quot wonder amp quot nontraditional medications that's being recommended by some, but unfortunately there's very limited data for it. It's true that mitochondrial ...
CREATININE AND POTASSIUM JUMPS WITH HEART MEDS | Cardiology | 03-2000
ACE inhibition is clearly cardiovascular protective, so consider it in all patients at high risk for vascular disease or those with established heart disease. Your patient had a previous coronary ...
GO BACK TO SQUARE ONE FOR ASTHMA AGONY | Respirology | 01-2000
Since the patient failed to respond to prednisone, all good doctors should reconsider the diagnosis. Are the symptoms due to fixed airflow obstruction, COPD, irreversible asthma, congestive heart failure, reflux ...
CALCIUM CHANNEL BLOCKERS AND CHF | Cardiology | 11-1999
ACE inhibitors have proven their value in the treatment of congestive heart failure by decreasing the progression of disease. ACE inhibition enhances survival as well as quality of life, and ...
MANAGING GOUT WITH COMORBIDITIES | Geriatrics | 11-1999
In this patient, I'd probably manage the acute attack with colchicine 1 mg every two hours -- to a maximum of 6 mg -- until the patient improves or intolerable ...
ACE INHIBITORS: FOR ALL DIABETICS? | Endocrinology | 09-1999
The answer to this question is still a year or two away -- but results of recent studies may be pointing in that direction. Control of hypertension, nephroprotection, and reduction ...
CAN IT BE ASTHMA WITH NORMAL LUNG FUNCTION? | Respirology | 05-1999
True asthmatics can have normal spirometry, especially if it's done when they're asymptomatic, but they'll always have a positive methacholine histamine challenge test, even when pulmonary function tests are normal. ...
WHAT'S NEW IN ATRIAL FIBRILLATION? | Cardiology | 04-1999
Atrial fibrillation is the most common of all cardiac tachyarrhythmias. It's rare in adults below 50 years of age less than 0.5 and quite common in the elderly, occurring in ...
WHO NEEDS ACE INHIBITORS? | Cardiology | 04-1999
Consider ACE inhibition for all patients with ejection fractions lower than 35-40 , as it prevents dilation of the heart, improves exercise tolerance and decreases the progression of heart failure ...
RENAL FUNCTION SCREENING FOR PATIENTS ON METFORMIN | Endocrinology | 07-1998
In a 1997 study from Saskatchewan, lactic acidosis as a complication of metformin treatment was found to occur at the rate of 9 cases per 100,000. Recently reported American data ...
