Practical Cardiology Editorial Staff 

I’d be interested in what Dr Bhatt says his screening would be in the patient who hasn’t had an event before, who has all their factors controlled, their diabetes, their blood pressure and lipids are controlled by the referring doctor. Some of our doctors do cardiac calcification scores, scares the patient, but they’re already on a statin and their LDL [low-density lipoprotein] is below 70 mg/dL, and I have them on the works of heart-smart drugs and all that. Some of them do stress tests, so I’d be interested in what screening is done. The cardiologists tend to do different things, so I’d be interested in what the guru does.

Dhiren Patel, PharmD, CDCES, BC-ADM, BCACP:

Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC:

 I think if it’s a tough situation, I just send them to an endocrinologist. That’s what I do. But assuming it’s not too challenging, generally speaking, the guidelines are pretty firm about what things to test for. It’s usually the simple stuff: LDL, cholesterol, blood pressure, glucose, weight. I actually prefer waist circumference, but I think weight or BMI [body mass index] are the more standard ones. Screen for smoking. Beyond that, everything else really is supposed to be symptom-driven. These days, the annual stress test per the guidelines is out, even though that remains a common practice. Any sort of imaging testing or invasive testing, in general, is meant to be driven by the presence of symptoms, such as suspected angina. Though coronary calcium you mentioned; there, that has been promoted in recent years as a way, if there’s really a question to be answered in terms of figuring out if a patient is at high risk. For example, a patient where maybe you think they need to be on a statin but there’s statin hesitancy. There perhaps getting coronary calcium can help tip things over where the patient says, “Oh yeah, I do have plaque in the coronaries. Maybe it’s time to go and start that statin.” I think there’s a role, but I suspect in years to come, there’s going to be a much more prominent role played by imaging tests, even in people who are asymptomatic. But at least per the guidelines, we’re not quite there yet.

 Thank you. Jen, how are you guys classifying this risk and screening?

Jennifer Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP:

 Community pharmacists are highly accessible, and almost every human being goes into a pharmacy at some point. I think that they also get to know their patients, just like in primary care, so they’re in a unique position to be able to say, “Hey, have you seen the doctor? Hey, have you been screened for this? Have you considered this? Have you talked about this?” I think that pharmacists in the community can help answer those questions or at least put it into patients’ minds that, “You need to go see your doctor. Have you had your blood pressure checked? Have you had your cholesterol checked? Have you considered these things?” Even to just make those suggestions, to make sure they’re seeing the appropriate providers. Then clearly the pharmacists who are within primary care or within cardiology and endocrinology are working with the team in terms of drug therapy management, but the community pharmacist is in that unique position.

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Criteria and types of health care professionals who may screen patients at high risk for cardiovascular disease.

Screening for Cardiovascular Disease

 Dr Busch, when you think about some of these risk factors that are associated with what Dr Bhatt just mentioned, how are you talking to your patients about these risk factors? I sometimes think about them as modifiable, nonmodifiable. And then, what are the efforts that you are doing, and we’ll maybe go around, of screening these cardiovascular risks? You’re very involved in clinical trial research. I feel like you’re constantly looking at panels and seeing who could potentially be at risk. So maybe talk to us a little about those risk factors and how your practice takes on the screening of these cardiovascular risks.

 For an endocrinologist, most of our patients have diabetes and mainly type 2 diabetes, but they don’t just come in with a diabetes, as Jen and others have said. They come in with diabetes, hypertension, hyperlipidemia, and obesity; they come in with hypertriglyceridemia. So, which one are we going to tackle first? Say they’ve done the lifestyle stuff, they’ve met with the diabetes educator, and you know they’re going to end up on 6 or 7 drugs down the line. Well, visit 1, you’re not giving them the works. You could, but then the patient will put their shoes and socks on and run away. You have to choose your battles first, and what you’re going to be successful with early. Oftentimes, the LDL [low-density lipoprotein] is the easiest thing to control because the statins work, and if they can tolerate the statin, at least you could show success after the first visit, that you got their LDL at a target, and then try to address the other things.

If they come in with an A1C [glycated hemoglobin] over 7.5%, you’re going to give them 2 drugs for diabetes and heart-smart drugs. You give them a statin, or a statin plus something else to get their LDL down. Now we have the REDUCE-IT trial that Dr Bhatt is famous for. You’re going to look at the triglycerides and do something about that as an additional marker. And then of course, their blood pressure. And even if their blood pressure is good, congratulations, you have good blood pressure, here’s your ACE [angiotensin-converting enzyme inhibitor] or ARB [angiotensin receptor blocker] based on the HOPE trial. Congratulations, your LDL is 92 mg/dL, here’s your statin based on the CARDS study, that statins should be in the drinking water of diabetes.

You have to roll out the regimen for the patient, and most of our patients, if you ask them what did they have for breakfast? Their answer is pills, because after a year, they’re on 6 or 7 medications and some injectables as well. So, each thing has to be addressed, because these are risk multipliers, and you want to address each thing. But it takes about 6 months to a year to roll out the full regimen that the patient is going to be on. But you’re not telling them day 1, especially if they come in saying, “I don’t want medications, I want to treat things the natural way,” and you know what you have cooking down the line.

 Absolutely. It’s a lot, especially as some of these medications start blurring and have cardiac benefits, you have different specialties that normally didn’t use them that are now using them. And we’re going to get to that. Joyce, when we started, you mentioned you spent a lot of time on both preventive cardiology and secondary prevention. From where you sit in the specialty arena, where you get to interact with endocrinologists and pharmacists and cardiologists, how do you go about what Dr Busch just mentioned, with primary prevention and secondary prevention? How do you tackle each of those?

Joyce Ross, MSN, RNC, CRNP, CS, FNLA, FPCNA:

 Well, I think the first thing I want to say is, I totally agree with Dr Busch that we really can’t just throw everything at the patient the first time we see them. They will run and they won’t come back. And the idea of multiple medications all at one time is something that me is a nurse practitioner, a person who sees the patient on a regular basis, even more than perhaps the physicians in the various settings, I’m kind of a gatekeeper in a lot of ways. At least for our practice, I would be able to make sure that everybody was getting the information. I think communication between the health care providers is critically important, because this is a team. And of course, the most important part of the team is that patient. So, for me, every time a patient is seen by any of a group, and it’s wonderful if you’re all in the same health system, and you can just pick up where you where you want to, but that’s not always ideal. But what happens, what is very important, is for you, as a provider, no matter what your entity is, to communicate with the others about what you saw, what you did, how the patient is doing.

And you know what? The most important thing to me is that patient gets that same letter, because they need the congratulations, they need that idea that, “look what we did.” Again, to go back to what Dr Busch was saying, we’re helping them and supporting them in the decision that they have to make to take a lot of medication. I think that the most important thing is to depend on all the team, communicate, but communicate first with the patient. My opportunities have always been to develop long-term relationships with the patients, because dyslipidemia is not something that’s going to go away. And I’ve taken care of patients from the time they’ve been 6 years old until out of college, married and have children. This long relationship that you have with them is critically important. As a nurse practitioner, I’ve been fortunate to do that, where many specialists don’t have that opportunity. When others communicate with me, I have a great chance of weaving their thoughts and plan into the overall plan. That’s how the team works.

Recommendations for establishing relationships and talking with patients about primary and secondary prevention against cardiovascular events.

Counseling Patients on CVD Risk Factors

An all-female panel of American Heart Association experts will be available to answer questions on the COVID-19 pandemic and the changes it has made to resuscitation and patient care.

The event will take place on Reddit in a Reddit Ask Me Anything event.

The AHA panel will focus on how the COVID-19 pandemic has led to fewer 911 calls, and why hospitals are still the safest place to be if a medical emergency such as a heart attack or stroke occurs. Drs. Sasson and Topjian will be available to answer questions on specific ways medical experts are addressing patients’ health during the pandemic, or questions about COVID-19 and emergency cardiovascular care. 
	
	What:             Ask Me Anything Q&A Session on Reddit
	
	When:            Friday, June 12, 1:00-2:00 p.m. CT
	
	Where:          

  
	
	Who:               Comilla Sasson, M.D., Ph.D., FAHA, FACEP, is vice president of emergency cardiovascular care science and innovation for the American Heart Association and an associate clinical professor of emergency medicine at the University of Colorado, Denver, where she is a practicing ER physician. She worked for one month on the front lines in New York City caring for patients with COVID-19.
	
	                        Alexis Topjian, M.D., M.S.C.E., FAHA, is a pediatric critical care medicine physician at Children's Hospital of Philadelphia and an assistant professor in the department of anesthesia, critical care and pediatrics at Perelman School of Medicine at the University of Pennsylvania.

Articles

American Heart Association Experts Will Answer Questions About COVID-19 and Emergency Cardiovascular Care 

A 40-year-old woman went to the doctor after petechia and palpable purpura appeared on the palms of her hands, fingers, and toes. She appeared chronically ill and had significant weight loss. Her doctor also noted the presences of Osler nodes. She did not have any recent injuries or skin punctures and reported she had been in good health until the last few weeks.  Based on these clues, how would you diagnose this patient?

A. Leukocytoclastic vasculitis
	B. Subacute bacterial endocarditis
	C. Candida sepsis
	D. Thrombotic thrombocytopenic pupura (TTP)

Not sure? Use the Differential Builder in 

To learn more about this diagnosis, visit the 

Image IQ: Petechia and Palpable Purpura on the Palms of Hands, Fingers, and Toes

In the face of the worldwide coronavirus (COVID-19) pandemic, 4 of the largest cardiology organizations are advising patients receiving treatment with ACE inhibitors (ACE-i) and angiotensin receptor blockers (ARBs) they should not be discontinuing treatment unless it is recommended by their physician.

The European Society of Cardiology (ESC) Council on Hypertension announced their stance in a positioning statement on March 13, and the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Failure Society of America (HFSA) published a joint statement days later on March 17-a move which showed solidarity in opinion between cardiologists, whose patient populations are among the most vulnerable during the outbreak.

“We understand the concern-as it has become clear that people with cardiovascular disease are at much higher risk of serious complications including death from COVID-19," AHA president Robert A. Harrington, MD, said in a statement. "However, we have reviewed the latest research-the evidence does not confirm the need to discontinue ACE-i or ARBs, and we strongly recommend all physicians to consider the individual needs of each patient before making any changes to ACE-i or ARB treatment regimens."

While research surrounding the topic is still limited, the discussion on whether ACE-i and ARBs should be discontinued as part of therapy has mostly been waged by cardiologists on social media. With evidence angiotensin-converting enzyme 2 identified as a functional receptor for SARS-CoV-2, which leads to COVID-19, many have raised the question as to whether it is appropriate to discontinue the aforementioned therapies.

The statement from the ESC Council on Hypertension, which was penned by Giovanni de Simone, MD, Chair of the ESC Council on Hypertension, references the debate taking place on social media and notes the concern this can cause for patients who may read it. The statement goes on to discredit the speculation, citing work in animal studies that suggests these medications might have benefit for preserving lung function.

“This speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it,” Simone and colleagues wrote. “Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.”

In the event a clinician has a patient with cardiovascular conditions that contracts COVID-19, the joint HFSA/ACC/AHA statement recommends delaying changes in treatment until after a full evaluation is complete. The statement also recommends shared-decision making with the rest of the patient’s care team before going forward with changes to treatment.

“While the primary symptoms of COVID-19 include respiratory symptoms, the latest evidence demonstrates some patients with COVID-19 may also have severe cardiovascular damage," said Biykem Bozkurt, MD, PhD, HFSA president, in the joint statement. "We must ensure we fully evaluate and treat patients with cardiovascular disease."

HFSA/ACC/AHA statement addresses concerns re: using RAAS antagonists in COVID-19

,” was published online in the AHA Newsroom.

Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers

,” was published online in the Council of Hypertension News.
	 

Cardiology Organizations Advise on ACE Inhibitors, ARBs Use During COVID-19

A 42-year-old man went to the ED complaining of acute onset of dizziness, heart palpitations, and a racing heartbeat. He's been working overtime at two jobs and has been drinking multiple energy drinks with high amounts of caffeine to stay awake. He reported multiple episodes of faintness over a short period of time and sought treatment. An ECG showed a wide QRS complex.

A. Ventricular tachycardia
	B. Vasovagal syncope
	C. Generalized anxiety disorder
	D. Myocardial ischemia

The correct answer is (A) ventricular tachycardia.

A cardiac arrhythmia originating from the ventricles. May be asymptomatic or may present with dizziness, palpitations, chest pain, shortness of breath, syncope, or sudden cardiac arrest. Characterized by a wide QRS complex (duration >120 msec), although supraventricular tachyarrhythmias may also exhibit a wide QRS complex when abnormal intracardiac conduction (aberrancy) is present. Distinction between these arrhythmias may be helpful for long-term treatment, although it may not be necessary for treatment of an unstable patient.

Ventricular tachycardia (VT) may be classified as:

Sustained or nonsustained – Sustained VT is defined as persistence for ≥30 seconds. Nonsustained VT is defined as duration of >3 beats but spontaneous termination within 30 seconds.

Monomorphic or polymorphic – Morphology of all QRS complexes is the same in monomorphic VT, whereas beat-to-beat variation in QRS morphology is seen in polymorphic VT.

VT is most commonly observed in patients with underlying structural cardiac abnormalities (including coronary artery disease, hypertrophic cardiomyopathy, dilated cardiomyopathy, and ion channel mutations such as Brugada syndrome and long QT syndrome), although some patients will present with idiopathic VT, which is defined by occurrence of VT in a structurally normal heart.

Treatment varies depending on the presenting symptoms and hemodynamic stability. Options may include cardiopulmonary resuscitation, electrical defibrillation, or use of antiarrhythmic drugs (eg, amiodarone). Patients with a history of life-threatening or recurrent VT will often undergo radiofrequency catheter ablation and/or placement of an implantable cardioverter defibrillator.

To learn more about this diagnosis and for ICD10 codes, visit 

A 42-year-old man visited the ED complaining of acute onset of dizziness, heart palpitations, and a racing heartbeat. He's been working overtime and drinking caffeinated energy drinks to stay awake. He said he had multiple episodes of faintness over a short period of time. Can you diagnose this patient?