Key BMJ learning points from recent BMJs
In cases of errors please read the original articles before using the information below to influence clinical decison making!
INOCA – myocardial Ischaemia with Non-Obstruction Coronary Arteries (i.e. less than 50% coronary artery obstruction). It is associated with increased risk of hospital admission, MI and increased all-cause mortality.
Suspect in patents who have had non-cardiac causes excluded (endoscopy, oesophageal manometry, abdo uss, endoscopy etc) and non-ischaemic cardiac disorders excluded e.g., myocarditis, pericarditis etc AND the patient had a history of: 1) Classical angina or 2) Ischaemic changes on ECG or 3) Impaired myocardial perfusion on stress testing or 4) Stress induced regional wall abnormality 5) Impaired coronary flow reserve.
Causes: Coronary artery spasm, coronary microvascular disorders, increased myocardial oxygen demand i.e., tachycardia or myocardial workload.
Usually need cardiology referral to establish the diagnosis and for Rx (symptomatic and preventing Major Adverse Cardiovascular Events MACE).
Statins – Trial of 200 patients (average age 69) who had stopped statins or were considering stopping statins due to M-S pain. Randomised to rotating cycles of placebo or statin. No difference in M-S symptoms between the two even within the same patient. M-S aches and pains are common and rarely due to statins.
LBP in the over 60s – Over a 12 month period ¼ to ¾ of > 60s will suffer LBP (risk increases with age). Serious underlying pathology is rare
Key questions to asses risk of serious cause in the > 60s
Cauda equinae (<1 in 1000 older adults) – diffuse neurological features, perineal numbness, new bladder or bowel dysfunction
Infection (<1 in 1000 older adults) – recent sepsis, unwell, immunosuppressed, recent spinal procedure or fever
AAA (<1 in 1000 older adults) – smoker, pulsation near the umbilicus, abdominal symptoms, arteriopath, multiple risk factors for AAAA
Vertebral fracture (7.5 in 1000 older adults) – acute onset, man > 64, woman > 74, osteoporosis, prolonged steroid use, especially if pain triggered by minor trip or fall
Malignancy (6 in 1000 older adults) – Persistent and or progressively worsening pain, night pain, local spine tenderness, PMH of cancer likely to metastasise to bone, unexplained weight loss. NICE recommend whole spine MRI (within 24 hrs if features of cord compression otherwise within 1 week). NB – NICE also recommend urgent abdo CT in patients with new onset back pain and abdo symptoms re ? pancreatic cancer (In addition of course to whole spine MRI).
Central lumbar canal stenosis (30 to 50 in 1000 older adults) – Bilateral buttock and thigh pain, on walking with relief with sitting or bending forward ‘pseudo claudication’.
Radicular pain (60 to 1000 in 1000 older adults) – unilateral leg pain following a dermatome distribution
No underlying specific pathology (600 to 900 in 1000 older adults) – so the vast majority of > 60s with LBP do not have sinister underlying pathology.
Imagining should be reserved for those patients with suspected underlying specific pathology
Diabetes: NICE guidance. All type 1 diabetics over the age of 4 should be offered real time (1st line) or intermittent flash (2nd line) Continuous Glucose Monitoring systems. Patients with Type 2 DM taking multiple insulin shots should have access to intermittent flash CGM if they have hypoglycaemic unawareness, have to test 8x or more a day or struggle with self-monitoring.
Conjunctivitis in the new-born. Ophthalmia neonatorum describes conjunctivitis in the first 28 days of life. Classically with red conjunctivae and discharge. All should be referred to hospital the same day due to risks of sight loss and considerable morbidity. Examine the lids, lid margins, cornea and conjunctivae. No need for fluorescein staining in GP, as it does not change your Rx plan. If there is no conjunctival injection then sticky eyes are most likely due to naso-lacrimal duct obstruction (manage in GP < 1 year). Investigation and empirical treatment in Primary Care is not necessary. Chlamydia accounts for up to 40% of cases (presenting 5 to 14 days after birth, may be unilateral or bilateral, may have thin pseudo-membranes when the lower lid is pulled down). Gonorrhoea causes a more acute infection but is much rarer < 1% (usually presenting within 2 to 5 days of birth with severe lid oedema and discharge). HSV is also a rare cause. Up to half of cases are skin, respiratory tract or GI bacteria spread from care givers.
Prosthetic joint infection: Early infections (0-3 months post surgery) present with the symptoms you might expect; pain, redness, swelling, reduced movement etc +/- systemic signs.
Delayed infections (3-24 months) may present acutely but may have far vaguer symptoms and signs; pain with reduced function but may have no signs of infection.
Late infections (>24 months) also may occur and are often secondary to another focus of infection
Invx; CRP and ESR, FBC, D-dimer
NB CRP will normally peak at day 3 post surgery and fall to normal by day 28, so raised CRP in this time period is not diagnostic of joint infection BUT in the first 90 days post-surgery CRP > 100mg/l or a rising CRP would be suggestive.
Delayed infection (> 90 days) suggested if CRP raised > 10 mg/l, D-dimer > 860ng/ml or ESR >30mm/hr. Joint radiographs have very low sensitivity. Clinical suspicion or abnormal tests = refer/liaison for urgent orthopaedic opinion.
Cluster headache – Intense (rated as worse than childbirth 9.7/10 vs 7.2/10), short lived (< 3 hours), frequent (daily or more frequent), unilateral attacks of facial pain behinds or around the eye with marked restlessness and autonomic features. May be preceded by lacrimation, nasal congestion or facial ache (minutes before) or mood changes / poor concentration (up to an hour before). Usually develops between 20 to 40 years of age. NB patients often are sensitive to sound and light and a minority may have nausea and vomiting. The shorter duration of pain and associated severe restlessness help differentiate it from migraine. Cluster headaches are more common in men and smokers. Alcohol is a common trigger.
Most have attacks over weeks or months often occurring on an annual cycle. Pain free remission are usually longer than 3 months.
Inx – MRI and neurology opinion
Rx Acute phase – 1st line Subcutaneous sumatriptan (2nd line triptan = nasal sumatriptan or nasal zolmitriptan) but beware contraindications to Triptans. May be used in combination with Oxygen or Oxygen alone if Triptans are contra indicated. Non invasive vagal nerve stimulation may also help abort attacks.
Transitional treatments - steroid injection or oral corticosteroids.
Preventative treatments – Verapamil 120mg (rapid release) tds is the first line preventative treatment but requires ECG beforehand, 1 to 2 weeks post every dose increase and 6 monthly thereafter (re PR interval prolongation).
Other drugs that may help in prevention include Melatonin, Lithium, Baclofen and Topiramate
Invx HT in younger patient i.e. < 40 years – Just over 1 in 10 people aged 35 to 44 years have hypertension. The majority have Essential Hypertension but 5% to 30% may have an underlying cause. The most common secondary causes are; thyrotoxicosis, kidney disease, fibromuscular renal artery stenosis and Primary Aldosteronism (starting around the age of 40). Secondary causes over the age of 40 are similar but thyrotoxicosis becomes very rare and Obstructive Sleep Apnoea becomes the commonest cause. Don’t forget alcohol, cocaine, steroids, cocp, liquorice, nsaids and antidepressants may also be a cause.
Initial invx in younger patients – eGFR AND electrolytes, urine ACR, urine dip test (blood and protein), Hba1c, non-fasting lipids, TFTs, ECG. Fundal examination, CVS examination including radio-femoral delay (CoA) and listening for renal bruits (2 to 3cm above and bilateral to the umbilicus as they are present in >70% of cases of renal artery stenosis. US-KUB if renal bruits are heard. US-KUB if kidney feels enlarged. BP in both arms (>20mmHg difference may indicate Coarctation of the Aorta ‘CoA’).
Spontaneous hypokalaemia (?Conns) or stigmata of Cushing’s should trigger referral for investigation. Only do urine catecholamines if a patient has symptoms of Phaeochromocytoma.
If a secondary cause is not suspected then start usual Rx but reconsider secondary cause if i) eFGR drops significantly after starting an ACE ii) K drops significantly after starting low dose diuretic iii) Resistant HT IV) Labile HT despite Rx.
Montelukast is used in asthma and allergic rhinitis in asthmatics. When combined with inhaled steroid (in adolescents and adults) it halves the risk of asthma exacerbation requiring steroid treatment. It usually works quickly (within 2 weeks) but it can cause new onset serious mental health side effects such as aggression, depression, suicidal ideation and nightmares. Neuro-psychiatric sides effects are however rare and usually mild and will often develop within the first few weeks of starting treatment. This risk should be discussed with patients and/or their carers and patients should be reviewed 1 month after Rx initiation to enquire about potential side effects and also at subsequent medication reviews.
Sustained or intermittent abnormal movement and posture caused by abnormal neural control of muscle contraction. Onset in adulthood tends to be isolated and focal. The three most common effect the neck (Cervical dystonia/torticollis), eyes (Blepharospasm) or be associated with tasks (Writer’s cramp). Regular botulinus toxin is the most effective therapy and all patients should be referred to a neurologist with an interested in movement disorder. A dystonic body part usually remains mobile but slow and effortful with reduced range of movement. Patients often have associated depression, anxiety or pain.
Task specific – usually develops in the mid 30s, effects men > women and relates to highly skilled tasks. Writer’s camp is the most common. It is also common in musicians.
Cervical dystonia – usually develops around the age of 45, effects women more than men, progresses over 6 to 12 months and then plateaus. Characterised by an involuntary twisting of the neck and head.
Blepharospasm – usually develops in the 60s, effects omen > men and the patient reports a gritty uncomfortable feeling before the onset of blepharospasm.
Recognising ACS – Half of patients do not call emergency services as their symptoms are not perceived to be related to serious health problem. This is especially true for women, the elderly and patients with multiple co-morbidities. Not everyone has classical chest pain radiating down the left arm at rest. Consider ACS in patients with new onset; chest pain, tightness or pressure, soboe, fatigue, palpitations, isolated discomfort in the throat, neck or jaw. Misdiagnosed or late diagnosed STEMI or Non STEMI have a dramatically higher mortality. So, if suspected, aspirin 300mg stat, oxygen if Pox < 94% in non COPD patients and emergency transfer to A&E. In A&E a risk assessment is made (e.g. using the HEART score based on risk factors, ECG changes and Troponin levels) as 6% of patients with ACS have normal ECGs.
NICE OA – Diagnosing OA: No need for imaging in patients > 45 who have activity related joint pain and have no morning stiffness or morning stiffness lasting < 30 mins. Greater emphasis on exercise and weight loss for pain reduction with analgesics such as Paracetamol and Opioids are not advised. Glucosamine should also not be advised as there is no strong evidence of benefit. The same goes for Acupuncture. GPs should offer tailored therapeutic exercise such as local muscle strengthening and general aerobic fitness. Supervised exercise is likely to be more helpful as it may increase adherence and social support.
Analgesics may be needed at the start of an exercise programme (pain gets worse before it gets better) but they should be used at the lowest dose for the shortest time possible. Topical nsaids should be first choice for joint pain, especially knee arthritis. If this fails consider oral nsaids but inform the patient of the risks and try the lowest possible dose for the shortest time. Walking aids may help people with lower limb arthritis.
Primary Aldosteronism (Conn’s syndrome) – More common than you might think. Primary Care screening of hypertensives reveals of prevalence of between 3 to 12%. Inappropriate secretion of aldosterone (usually due to adrenal adenoma or hyperplasia) causes supressed renin levels and raised aldosterone resulting in hypertension and excess cardiovascular mortality. Not all patients have hypokalaemia (only about 30%). Patients may have symptoms related to hypokalaemia e.g. muscle cramps, weakness and cardiac arrhythmia.
Consider the diagnosis in moderate to severe HT or resistant HT or HT with unprovoked hypokalaemia. The screening blood test is plasma Aldosterone to Renin Ratio (ARR) performed two hours after getting up and being ambulant 15 minutes after remaining seated before the blood test. It is not a perfect test. Many drugs interfere with the ARR test
Replace thiazide or loop diuretics, spironolactone or amiloride 4 weeks prior to the test.
Replace ARBs, ACE inhibitors, Amlodipine/Felodipine or Betablockers 2 weeks prior to test.
If possible, stop cocp and test to be done in natural follicular phase.
Antihypertensives that don’t interfere with the test include alpha blockers e.g. Prazosin, or other antihypertensives such as Moxonidine, Verapamil and Hydralazine.
If the test is abnormal refer to an endocrinologist for more definitive testing e.g. fludrocortisone suppression test. Patients may then need adrenal CT with adrenal vein venous sampling.
Rx is usually surgical (Laparoscopic adrenalectomy) or medical e.g. Spironolactone