We recap the top pearls on angina, Stable CAD, Heavy Menstrual Bleeding, and Hypercalcemia. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
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Featuring CardioNerds’ team members Drs. Dan Ambinder and Rick Ferraro and production by Molly Heublein and Graphics by Beth Garbitelli
Matt’s Pearl – All stable angina has to start somewhere. That’s why stable angina and unstable angina can sometimes be difficult to delineate. The latter represents an acute change in symptoms that should be investigated.
Stable angina occurs when coronary atherosclerosis builds up over time, and symptoms (nausea, dyspnea, chest pain, etc.) are unmasked by stress. Unstable angina (UA) is an acute coronary syndrome with plaque rupture or erosion, acute thrombosis, and rapidly evolving symptoms (Dynamed ACS, 2021).
Note: Dr. Ferraro pointed out that UA is a less common diagnosis in the era of high-sensitivity troponin testing, resulting in more cases of unstable angina being more appropriately diagnosed as NSTEMI (non-ST-elevation myocardial infarction) –expert opinion.
Paul’s Pearl – A noble goal is preventing ischemic heart disease, and we discussed risk stratification and management (see 4+ 2 figure below). Risk stratification includes assessing qualitative risk (lifestyle-associated risk factors), quantitative risk (through a risk calculator), and risk enhancing factors (like family history). To further personalize risk you can consider coronary artery calcium scoring. This is important because the management of stable angina focuses on minimizing symptoms and optimizing risk factors. Importantly, studies to date have not shown mortality benefit for PCI in patients with stable angina (e.g. Oribta, Ischemia trials).
Watto’s Pearl – Focus on life-prolonging therapies: statins, low-dose aspirin, healthy diet, exercise, smoking cessation, blood pressure control. Antianginals only address symptoms. Beta-blockers are life-prolonging in ACS (and HFrEF), but not for chronic stable angina.
Matt’s Pearl – Not all stable CAD is obstructive (i.e., discrete large artery stenosis) and stable angina may occur in the absence of a discrete obstruction, especially in women. INOCA stands for ischemia with no obstructive coronary artery disease. It’s believed that microvascular disease/dysfunction occurs in INOCA, and may cause angina. Stress testing and EKG may be positive in INOCA, but focal large artery stenosis is absent on angiography. Treatment consists of aggressive risk factor modification (treatment of comorbid conditions, exercise, smoking cessation, etc.), and antianginal therapy. Advanced imaging studies (e.g. cardiac MRI or PET) may aid in diagnosis –this is evolving. (Dynamed INOCA, 2021)
Check out Beth’s amazing graphic on cardiac imaging in the full show notes.
Featuring Dr. Bethany Samuelson Bannow production by Avital O’Glasser
Paul’s Pearl – A good way to start the menstrual history is to ask the patient to tell you about their periods. Follow up questions include how many days duration and the passage of clots. Also ask about impact on quality of life–does the patient miss work or school? Family history of heavy periods is also essential. To assess for heavy menstrual bleeding, ask if periods are moderate, heavy, or very heavy. The answer “very heavy” is a pretty reliable predictor of heavy menstrual bleeding. Other good questions include asking if the patient wears a pad and tampon together, if they have ever taken an iron supplement, or been diagnosed with iron deficiency.
vWF deficiency is common ~1% of the population. Ask about mucocutaneous bleeding from gums, the GI tract, rectum, epistaxis. Also ask about postpartum bleeding lasting beyond 6 weeks. Dr. Samuelson Bannow starts with PT, PTT, and Von Willebrand’s panel (VW antigen, VW activity, and Factor VIII) in addition to a ferritin. (Dynamed vWF 2021)
Matt’s Pearl – Consider NSAIDS, or Tranexamic acid for treatment of heavy menstrual bleeding (HMB). Note: Transexamic acid DOES NOT CAUSE CLOTS and can be valuable for HMB (ex. 1300 mg TID for 5 days). Dr. Bannow does not start transexamic acid in patients with a new clot as she’d worry about extension of that clot. Hormonal contraception is also an option for HMB. Dr. Bannow prefers long acting reversible contraceptives (LARCs), especially to lessen heavy menstrual bleeding caused by therapeutic anticoagulation.
With Dr. Carl Pallais. Production and graphics by Nora Taranto
Matt’s Pearl – When you see elevated calcium, first repeat it. Then, check metabolic panel, phosphorus, albumin (so you can correct for albumin), PTH, and 25-OH Vitamin D. It’s important to determine if elevation is PTH-mediated. A phosphorus level is a quick marker of whether PTH is turned on or off. (Low Phosphorus = PTH receptors may be activated, either by PTH or PTHrP; calcium, supplements, magnesium or aluminum containing antacids, and certain IV iron preparations can also lower phosphorus levels) —Dr. Pallais’ expert opinion.
Matt’s Pearl –
PTH mediated causes include primary hyperparathyroidism, Familial hypocalciuric hypercalcemia, Lithium.
Non-PTH mediated includes PTHrP, malignancy, excess calcium/Vit D intake, and granulomatous diseases, hyperthyroidism, and multiple myeloma. Check: SPEP, SFLC, 1-25 OH Vit D, TSH, and a skeletal survey (Dr. Pallais’ expert opinion)
Note: Dr. Pallais points out that a patient may be fine taking mega doses of Ca and Vit D until they become hypovolemic and develop AKI. Then, they develop milk-alkali!
Paul’s Pearl – Thiazide diuretics can be a cause of hypercalcemia by increasing calcium reabsorption. BUT, there are homeostatic mechanisms in place to prevent this, so hypercalcemia in the setting of thiazide use hints at primary hyperparathyroidism. There are guidelines to help determine who might benefit from surgery, which include age under 50 (ultimately more cost-effective and longer lead time for complications), significant hypercalcemia (>1 mg/dL above normal range), renal dysfunction (a little controversial; it predisposes patients to bone loss), kidney stones or risk of kidney stones (consider renal imaging and urine stone risk profile), or history of fragility fractures (so consider DEXA and vertebral fracture analysis) —2014 Guidelines by Bilizekian et al JCEM.
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Drs. Watto and Williams report no relevant financial disclosures.
Watto MF, Williams PN. “#287 Angina, Stable CAD, HMB, Hypercalcemia (TFTC #7)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date July 28, 2021.
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