This is an excerpt from a Consultant physician’s ( as well as life long learner’s) daily log in the Melaka Hospital wards. Names (physician and patients) have been eliminated to preserve privacy: 

Started from the so called high dependency unit—

B/n-6 Dm 10 yrs with CRF and presently treated for fluid overload--Need to look up renal dose modification for allopurinol and simvas?

Seems better today on the 15th and shall probably go home after a review from Nephro. Also found that he had come this time for fever that may have precipitated a CCF.

Caught some discussion between a consultant and the MO on what I guessed might be indications for stopping a beta blocker related to prolonged PR intervals in usual patients on beta blockers and felt too shy to clarify if this was the topic but decided to look it up anyhow. When I couldn’t get anything on the net mailed  the consultant to clarify and here’s the response:

“PR interval prolongation ….was 1st degree heart block and don’t we worry about further Brady? Except the latest beta blockers which are claimed to be safer, here they use 200mg metoprolol twice daily and follow ups are infrequent once in 4 or 5 months, hence the precaution”.

Read up Hurst and found this in beta-blockers and AMI—

Although β-blockers may be useful in many patients with AMI, some patients have contraindications to the use of this class of drugs. Relative contraindications include heart rate  <60 bpm, systolic blood pressure <100 mmHg, moderate or severe left ventricular failure, shock, PR-interval on the electrocardiogram >0.24 seconds, second- or third-degree heart block, active asthma/reactive airways disease

Now that I know this I wonder why I was so difficult to convince initially about utility of PR intervals in monitoring beta-blockers?



B/n 5--Even this guy has DM and Htn for 10 years. What’s this world coming to? Also seems to have cor pulmonale due to destroyed lung due to ? old Kochs or ?COPD. Presently with respiratory failure and right ventricular failure…not quite… after a review on the 15th, where I concluded that it may be all chronic LVF with CCF after all. The person probably needs a fresh echo to demonstrate a bigger LVIDd with a poorer EF than his last documented 3 months back.

B/n 4--Chronic LVF due to (? CAD with acute exacerb due to ? fresh coronary). Well, added AR to my knowledge about this patient today that I had somehow missed catching yesterday.

 
Some drugs I need to look up-
1)   Trimetazidine--I always thought this was useless?? But a systemic review through pubmed shows that there may be some benefit (although I am still not convinced). Even the MO said (rather diplomatically I thought) that it was being given to optimize cardiac function and pain. 
Isolation wards: There was this patient with Toxic epidermal necrolysis who had been started on IV Ig by the dermatologists. I searched pubmed for some evidence on the efficacy of IV Ig in TEN or SJS and found this abstract (copied below)…

Treatment of epidermal necrolysis with high-dose intravenous immunoglobulins (IV Ig): clinical experience to date.
Faye O, Roujeau JC.
Department of Dermatology, Hopital Henri Mondor, Universite Paris XII, Creteil, France.

High-dose human intravenous immunoglobulins (IV I ) have now been used as a treatment for epidermal necrolysis for several years.We have reviewed all series involving more than nine patients treated with high-dose IV Ig for toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS) published in indexed journals. Nine series included a total of 156 patients; among the 156 reported cases, 32 patients died (20.5%). When the analysis was restricted to the five series that included some comparison with expected deaths, the mortality rate observed in patients treated with IV Ig was 27% versus an expected rate of 30%. Because of high diversity in study designs and dosages of IV Ig used, and because several series included duplicate cases, it was not possible to make more detailed statistical analyses, including individual prognostic factors and IV Ig dosages.In the absence of randomised controlled trials, this review does not provide a definite conclusion on the usefulness of IV Ig in SJS or TEN; however, the analysis of published data does not suggest a dramatic efficacy. We conclude that, in the absence of further studies, IV Ig cannot yet be considered the standard of care for SJS or TEN.
This didn’t suggest much efficacy but then our patient was recovering although it may have been a spontaneous recovery. The Govt was sponsoring his IV Ig. Can be quite expensive otherwise (almost equivalent to buying a new car, someone commented).
 
Out of isolation wards:

B/n 11—Documented Hypoglycemia who came with giddiness. Was found to have a high CK (creatine kinase) levels around 2000 on 14/8. Today at 16/8 the CK was 400. Trop T was negative. MO had started on heparin and was treating him as an atypical NSTEMI.
1) How do we know that it was a NSTEMI (non-ST elevation myocardial infarction) with an atypical presentation just on the basis of CK?
2) What is the role of heparin in NSTEMI?

The last question, which I had asked, myself was one of the most confusing ones I have managed till date. I was thinking from the angle of indications of heparin in STEMI (ST-elevation myocardial infarction) and had forgotten that NSTEMI is for all practical purposes unstable angina (UA) where heparin is the mainstay of treatment. At least that is how the guidelines seem to suggest--The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction (UA/NSTEMI) J Am Coll Cardiol. 2000; 36: 970–1062.

Learning points for the day—

1)   Long-term beta-blocker therapy can be monitored with serial EKG (PR intervals) to prevent complications that may lead to bradyarrhythmias.
2)   CCFs can very often mimic corpulmonales
3)   Trimetazidine is very much in use ( and there may be some evidence to support it)
4)   TEN is often treated with steroids but more evidence is still needed to justify its regular use.
5)    NSTEMI and UA are managed similarly for all practical purposes.