Dr Rob 🫀🩺 🇦🇺
@drhungo
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Primary Care Physician | Educator | Supervisor | ASCVD, 🫀Failure, Diabetes | Addicted to🏃♂️&🏌🏼♂️ Follows Jesus, loves family, tweets≠medical advice @RACGP
New South Wales
Joined September 2015
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Last Seen Profiles
Pinned Tweet
How do lipid lowering 💊 💉 work ⁉️
🔹 ⬇️ absorption of cholesterol from the gut (ezetimibe)
🔸 ⬇️ the synthesis of cholesterol in the liver (statins, bempedoic acid)
🔹 ⬆️ liver clearance of LDL 👉🏼 by inhibiting the PCSK9 pathway (Inclisiran, evolocumab)
Whilst cholesterol
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BNP basics 📚
Myocardial wall stress causes proBNP secretion which is then cleaved into
👉🏼 BNP (biologically active)
👉🏼 NT-proBNP (inert)
BNP is protective against 🫀 remodelling & inhibits
🔸 RAAS 👉🏼⬆️diuresis💦natriuresis🧂
🔸Sympathetic activity 👉🏼 ⤵️ BP
NT-proBNP ⬆️
2
139
536
Why do I prefer atorvastatin & rosuvastatin?
💊 Potent - 50% LDL ⤵️ at high dose
💊 Can be taken day or night 🌃
💊 Absorption not affected by food 🍲
💊 ESRD 👉🏼 atorvastatin*
💊 SAMS 👉🏼 rosuvastatin**
* Only 2% of Atorvastatin is renally excreted & thus is my 🥇choice in
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480
@BrownHospMed
Geographic tongue (benign migratory glossitis)
Inflammatory disorder of unknown aetiology causing local loss of filiform papillae
👤 can have numerous exacerbatn’s/remissions
Associated with
👉🏼 atopy
👉🏼 psoriasis
👉🏼 reactive arthritis
💊 symptomatic therapy
#Medtwitter
5
75
465
Cholesterol made easy 🎓
Cholesterol moves through the body inside of lipoprotein particles, which are made up of 2 components
🔸Core 👉🏼 Cholesterol ester & TG
🔹Membrane 👉🏼 apolipoproteins, phospholipids, free cholesterol
Lipoproteins can be divided into
🔸Pro atherogenic
2
107
381
How do I approach statin associated muscle symptoms (SAMS) ?
💪🏼 confirm SAMS with history & CK
💪🏼 🔄 to hydrophilic statin
💪🏼 ⬇️ statin + add ezetimibe
💪🏼 Add bempedoic acid
💪🏼 Add PCSK9i*
💪🏼 Rechallenge with statin at 12 months
🔑 Only stop statin ❌ if symptoms severe or
2
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374
Heart failure in 2023
❤️ ALL HF patients are at EXTREME risk of CVD events, with ☠️ similar to cancer
❤️ CHAMP-HF showed 👩🏼⚕️ 👨🏼⚕️ are falling asleep at the wheel (clinical inertia)
❤️ Rapid initiation of all 4 pillars is safe, effective & improve 💊 tolerability (STRONG-HF)
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The power of combination lipid lowering therapy 👇🏼
💊 Atorvastatin 10mg/ezetimibe 10mg has > LDL ⬇️ than atorvastatin 40mg
🧪 Nature doesn’t care how you lower LDL
🔑For every 1.0 mmol/L ⤵️ in LDL you get a
❤️22% ⤵️ in CV events
❤️10% ⤵️ in all-cause ☠️
#CardioTwitter
17
83
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@DrPharmDMDTh
Finkelstein test ‼️
🍖 abductor pollicis longus & extensor pollicis brevis tendons
🩺 de Quervain tendinopathy
🩹 forearm-based thumb spica splint with the interphalangeal joint free
💊 NSAIDs +/- corticosteroid injection
#MedTwitter
#MedEd
0
20
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The ABC of lipids 📚
C - cholesterol 👉🏼 packaged into lipoproteins to be 🚗 to tissues for use
B - apolipoprotein B 👉🏼 the primary lipoprotein & carrier for LDL, VLDL, IDL & Lp (a) that play 🔑 role in atherogenesis
A - Lipoprotein (a) 👉🏼 variant of LDL, 🧬 determined &
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@BrownHospMed
Thromboangiitis obliterate (TAO)
Inflammatory, nonatherosclerotic, occlusive vascular dx
👉🏼 small/medium artery & veins
👉🏼 upper & lower extremities
🩺 criteria
🚭 <50yo
🚭 🚬 history
🚭 distal extrem ischaemia
🚭 +ve U/S
🚭 exclusion of autoimmune dx
#MedTwitter
#MedEd
1
23
170
LDL-C lowering with different 💊 💉
Moderate statin - 30%
High intensity statin - 50%
HIS + ezetimibe - 65%
HIS + EZE + PCSK9i - 85%
Early combination LLT saves ❤️
#MedTwitter
#CardioTwitter
#MedEd
#FOAMed
2
50
172
Iron deficiency ⚔️ heart failure
Fe deficiency associated with 👇🏼
🍖 50% of chronic/80% acute HF 👥
🍖 ⬇️ functional status, ⬇️ exercise cap
🍖 ⬆️🫀remodelling, 🏥tion & ☠️
Trials to date 📚
✅ AFFIRM-AHF, IRONMAN 👉🏼 smaller studies, higher risk population
🚫HEART-FID
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SGLT2 side effects 💦🍭
🚨 We need to move past the immediate cessation of SGLT2i due to UTIs & genital infections
👉🏼 These 💊 improve CV, HF & renal outcomes in the right 👥 & the absolute risk of SE is tiny
🔑 keep the 💊* & 🥇 consider other ways to improve genital ie
2
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@BrownHospMed
Distal radius fracture, specifically collies’
Young ➡️ high energy trauma
Old ➡️ low energy 🤔 osteoporosis
Mechanism ⏩ FOOSH (fall on outstretch hand)
🚨 emergency referral for
👉🏼 open #
👉🏼 neuropathy
👉🏼 compartment syndrome
👉🏼 vascular compromise
#MedTwitter
3
24
153
@BrownHospMed
Hordeolum (stye)
acute eyelid inflammation ➡️ p/w localised painful & erythematous swelling or nodule
Can be external or internal & arise from glands in the eyelash follicle or lid-margin
⏰ most spontaneously resolve <2/52
🩹 warm compresses
🔑 preseptal cellulitis is rare
2
21
151
@BrownHospMed
Serotonin (5-HT) syndrome
🔑 most cases develop within 24hrs of a new/change in 5-HT 💊
Clinical diagnosis ➡️ Hunter Criteria
Treatment
👉🏼mild ➡️ supportive / benzo’s
👉🏼 moderate ➡️ 5-HT antagonist
👉🏼 severe ➡️ paralysis + intubation
#MedTwitter
#MedEd
#FOAMed
2
25
146
@BrownHospMed
Felty syndrome
Severe subset of rheumatoid arthritis complicated by neutropenia & splenomegaly
Assos with ⬆️ risk of bacterial infections of the 🫁 & skin
🔑 often requires bone marrow 💉 to exclude other causes of neutropenia
💊 initial Rx ➡️ methotrexate
#MedTwitter
2
24
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@BrownHospMed
Anticholinergic poisoning
⏩ Angel trumpet (brugmansia) ingestion
Symptoms
🌱 ⬆️ HR
🌱hot flushed dry skin
🌱disorientated/delirium/seizures
🌱⬇️ bowel sounds & urinary retn
💊 ABC, benzo’s +/- physostigmine
#MedTwitter
#MedEd
#FOAMed
0
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137
In whom & why do I use Semaglutide?
💉T2DM 👉🏼 SUSTAIN-1 ⬇️ HBA1c
💉T2DM 👉🏼 SUSTAIN-6 ⬇️ MACE
💉Obs+HFpEF 👉🏼 STEP HFpEF ⬆️ QOL
💉Obesity+CVD 👉🏼 SELECT ⬇️ MACE
💉T2DM+CKD 👉🏼 FLOW* ⁉️
* Trial stopped early due to evidence of renal protection
🔗 SUSTAIN-1
2
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135
Familial hypercholesterolemia
Caused by functional mutation in 1 or more of the genes affecting
🧬 LDL receptor
🧬 PCSK9
🧬 Apolipoprotein B
⤵️ LDL-C catabolism 👉🏼 leading to
❤️ extremely ⬆️⬆️ LDL-C
❤️ propensity to early onset ASCVD
#MedTwitter
#MedEd
#CardioTwitter
3
36
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@BrownHospMed
@Radiopaedia
Ewing sarcoma
Part of a spectrum of neoplastic diseases known as the ES family of tumors (EFT) ⤵️
EFTs ➡️ 2nd most common primary 🦴 malignancy in kids
Mostly p/w pain and found on 🩻in the long 🦴 & pelvis
#MedTwitter
#MedEd
#FOAMed
0
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Assessing CV risk 🩸
🧪 apoB plasma levels 👉🏼 reflect the concentration of proatherogenic lipoproteins very low-density lipoprotein & low-density lipoprotein, whereas
🧪 non–HDL-C levels 👉🏼 reflect the concentration of cholesterol transported by these particles
Both are 💪🏼
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@BrownHospMed
@Radiopaedia
Supracondylar fracture
60% pediatric elbow #’s
Asses ⤵️
👉🏼 neurovascular compromise
👉🏼 compartment syndrome
👉🏼 fracture displacement
Analgesia before 🩻
Nondisplaced Type I➡️ long arm splint with orthopedic f/u
Type II-III or complications 👆🏼➡️ urgent ortho
Pic: coreem
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🫀 ASCVD paradigm shift 🫀
LDL needs to be the treated in a similar way to hypertension
❤️ Early combination LLT (HIS+EZE)
❤️ Up-titrate until goal LDL (<1.4)
❤️ hit different targets (⬆️ LDL rec expression, ⬇️ LDL rec♻️)
A job half done, is a job not done
#CardioTwitter
0
37
105
@BrownHospMed
Pellagra “raw skin” ➡️ vitamin B3 ⬇️
Symptoms
🍖 ☀️sensitive pigmented dermatitis
🍖 diarrhoea
🍖 dementia
In developed countries seen ⤵️
👉🏼 🍻 use disorder
👉🏼 post bariatric 🔪
👉🏼 anorexia
👉🏼 malabsorptive dx
Source ➡️ plant & 🐄 products
#MedTwitter
#FOAMed
#MedEd
1
21
105
@BrownHospMed
Metastatic testicular cancer
Most common malignancy for men 15-35yo & normally p/w painless testicular mass. 95% 5 year survival rate with 🏥
🩸- hCG, AFP, LDH
🩻 - CXR, CT chest/abdo/pelvis
👨👩👧👦 - cryopreservation
#MedTwitter
1
10
105
@BrownHospMed
@Radiopaedia
Renal infarction
Under recognised because it mimics ➡️ nephrolithiasis & pyelonephritis
Major causes
👉🏼 thomboemboli - 🫀emboli disease
👉🏼 insitu thrombus - renal art, ⬆️coag
🔑 if flank pain w/o 🪨 or +ve urine ⤵️
🩻 contrast CTKUB to asses for infarction
#MedTwitter
1
6
105
Lp(a) | Prof Florian Kronenberg
❤️ Lp(a) is an independent risk factor for CVD & should be measured at least once in a 👥 lifetime
If Lp(a) is ⬆️ we should 👇🏼
🔹Test the family, much like what we do in FH
🔹⬇️ modifiable CVD risk factors (ie LDL) as early as possible
3
31
105
@BrownHospMed
Phlegmasia cerulea dolens
↪️ massive iliofemoral DVT
Risk factors
🩸🏔 50-60yo, female
🩸malignancy 20-40%
🩸other normal DVT risk factors
🩹 thrombolysis / thrombectomy
⚠️ monitor for compartment syndrome
#MedTwitter
#Meded
#FOAMed
Before and after lysis 👇🏼
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#EASCongress2024
in review 🎥
If Lp(a) level is not considered in a risk estimation 👉🏼 ASCVD risk might be substantially underestimated ‼️
🧪 Lp(a) should be checked once in all adults
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
1
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❤️ ESC LDL goals for ASCVD risk ❤️
🧮 Conversion - mmol/L ↔️ mg/dL
- Low 👉🏼 3.0 / 116
- Moderate 👉🏼 2.6 / 100
- High 👉🏼 1.8 / 70
- Very High 👉🏼 1.4 / 55
- Very High*👉🏼 1.0 / 40
* 2nd event within 2 years
📉 High-V High require LDL 🥅 above + >50%
3
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@BrownHospMed
Scabies
Skin infestation ➡️ Sarcoptes scabiei
Transmission ➡️ prolonged skin-skin contact ie 👨👩👧👦 members, sexual partners
Causes
🐛 ⏫⏫ pruritis
🐛 erythematous papules ➡️ not above shoulders
💊 topical permethrin, Rx contacts, hot wash linen, 🔁 @ 1/52
#MedTwitter
1
16
92
@BrownHospMed
Lichen planus
Can affect skin, 💅🏼, or mucous membranes
Cutaneous LP p/w pruritic, polygonal, violaceous papules &/or plaques with overlying white (lacelike) pattern
post-inflammatory hyperpigmentation is common
🩹 ⬆️ pot topical/intralesional steroids
#MedTwitter
#MedEd
1
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Patients with known ASCVD are at ⬆️⬆️ risk of future 🫀events
LDL ⤵️ has been shown in 👇🏼
❤️ statins (JUPITER)
❤️ ezetimibe (IMPROVE-IT)
❤️ Bempedoic acid (CLEAR)
❤️ evolocumab (FOURIER)
❤️ Inclisiran (ORION-10)
🚨 With a meta analysis in 2018 showing a 22% ⬇️ in major
2
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@BrownHospMed
Henoch-Schönlein purpura (HSP)
Common vasculitis of childhood,
👤15/100,000 🏔 4-6yo
Clinical dx ⏩ purpura, arthralgia, abdo pain, kidney dx
💊 Pain ➡️ naproxen/prednisone
🏥 ➡️ dehydrated, ⏫ pain, GIT 🩸, significant kidney dx
⚠️ monitor chronic🫘 dx
#MedTwitter
1
13
95
@BrownHospMed
Koplic spots ⏩ measles
⬆️⬆️ contagious 🦠 illness
📝 fever, malaise, cough, coryza & rash (maculopapular, face then body)
👤 contagious approx 5/7 before & after rash
🧪 🩸IgG, throat & urine viral culture
💊 supportive, Vit A +/- ribavirin
#MedTwitter
#MedEd
0
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90
Clinical inertia is ☠️ our patients ‼️
Lipid lowering therapy should be considered start at the first sign of subclinical ASCVD 👉🏼 plaque progression prevention
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
3
25
94
Lipoprotein(a) - fast take 🎬
🔸Lp(a) is an LDL lipoprotein with
🔹an apolipoprotein(a) bound to apoB
🔸affects 1/5 👤 & 90% 🧬 determined
🔹reaches adult levels by 5-9 yo
🔸has highly atherogenic properties‼️
⚠️ Is an independent & causal risk factor for ASCVD
🔑 should be
2
30
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@BrownHospMed
Trousseau sign ➡️ hypocalcaemia
Causes
👉🏼 hypoparathyroidism
👉🏼 vit D deficiency
👉🏼 kidney failure
👉🏼 acute pancreatitis
👉🏼 severe infection
👉🏼 Mg deficiency
👉🏼 Metabolic alkalosis
#MedTwitter
#MedEd
#FOAMed
3
15
87
@BrownHospMed
Glucagonoma
Neuroendocrine tumor, often distal pancreas, 50-80% metastatic at 🩺
👥 0.1/1000,000 🏔 50yo
📝 necrolytic migratory erythema, chelitis, diabetes, anaemia, ⬇️ weight, chronic 💩
🩻 multi phase contrast CT
#MedTwitter
#MedEd
#FOAMed
0
7
85
How do I use advanced lipid lowering therapy (when above 🎯 on HIS+EZE) ⁉️
💉 ⏫️ CV risk 👤👉🏼 Ali/evolocumab
💉 Poorly compliant 👤 👉🏼 Inclisiran
Ali/evolocumab ⤵️ LDL by approx 60% but require 2-4 weekly injections
Inclisiran ⤵️ LDL by approx 50% but injection is 6
1
27
85
@BrownHospMed
Sézary syndrome
Distinctive erythrodermic cutaneous T cell lymphoma w leukemic involvement by malignant T cells
Can present de novo ➡️ typical skin, blood & nodal involvement or
👉🏼 may evolve from patch/plaque or erythrodermic mycosis fungoides
#MedTwitter
pic
@Sthanu5
0
15
83
@BrownHospMed
Tetralogy of Fallot
➡️cyanotic congenital🫀disease that affects 4/10,000 births
Characterised by
👉🏼 Right ventricular hypertrophy
👉🏼Ventricular septal defect
👉🏼 Overriding aorta
👉🏼RV outflow tract obstruction
#MedTwitter
#MedEd
#FOAMed
0
12
82
@AvrahamCooperMD
Probability diagnosis is inflammatory bowel disease with clubbing being more common in Crohns 👌🏼
Inflammatory bowel dx tips 👇🏼
💩 29/100,000 ⤴️ 3-5th decade
💩 Long term rem 🚫 steroids 🥅
💩 44% of crohns, 16% UC require biologics
💩 1st deg 👨👩👧👦 20x risk
💩 antibiotics at young age ⤴️ IBD risk
💩 MRE useful for 🔎 small bowel crohns
1/2
#MedTwitter
#MedEd
#poo
1
6
20
1
3
79
@dermatology
Herpes zoster (shingles)
👉🏼 reactivation of latent VZV infection within the sensory ganglia
🩺 vesicular rash + acute neuritis that follows a dermatome
💊 antiviral therapy if within 72 hours, simple analgesia, prednisone for severe pain
#MedTwitter
#MedEd
#FOAMed
0
9
79
@BrownHospMed
@IhabFathiSulima
@grepmeded
Magnetic gait disorder (MGD)
MGD + 🧠 impairment + urinary incontinence ➡️ Normal pressure hydrocephalus
⏫ ventricular size with normal opening pressures on LP, occurs in 1 per million 👥
📝 cognitive testing & rule out other causes of gait dysfunction
🩻 MRI
#MedTwitter
1
4
81
Cardiac amyloid | HFpEF Masquerades
🌎 6-16% of 👥with HFpEF & ⬆️ >60 yo
Suggestive 🩺 findings
❤️ unexplained LVH
❤️ autonomic dysfunction
❤️ peripheral neuropathy (carpal tun)
❤️ CKD + proteinuria
❤️ Other: GIT🩸, macroglossia, purpura
🩸 SPEP, UPEP + immunofixation,
2
21
74
❤️ risk assessment | Lp(a)
Lp(a) 👉🏼 LDL-like lipoprotein with covalently bound apo(a), are ~90% 🧬 determined & is an independent CV risk factor ⚠️
Once in life testing is recommended to
🧪 Aid 👨🏼⚕️ in decision to treat with LLT
🧪 Identify cause for ⬇️response to LLT
🧪
1
22
79
@BrownHospMed
@LITFLblog
Brugada syndrome
Autosomal dominant 🧬 disorder with ECG changes that ⬆️ risk of ventricular tachyarrhythmias & sudden🫀 ☠️
🔑 ICD ➡️ prevent of🫀arrest + 🧬 screening
#Medtwitter
#MedEd
#FOAMed
0
8
76
#EASCongress2024
in review 🎥
Aggressive LDL ⤵️ & cognitive function
Statins 👉🏼 safe for the 🧠
Ezetimibe 👉🏼 safe for the 🧠
HIS+EZE+PCSK9i 👉🏼 safe for the 🧠 ‼️
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
3
23
78
@BrownHospMed
Dermatitis herpetiformis
Intensely pruritic skin eruption characterized by
👉🏼 inflammatory papules & vesicles
👉🏼 often excoriated
👉🏼 elbows, forearms, knees, buttocks, back & scalp
Assos ➡️ gluten sensitivity ie coeliac dx
🔬 direct immunofluorescence
#MedTwitter
0
13
76
@BrownHospMed
Steeple sign ⏩ croup
inflammation ➡️ larynx/subglottic airway causing
👉🏼inspiratory stridor
👉🏼barking cough
👉🏼hoarseness
👤< 6yo 🏔 6mo-3yo
🦠 parainfluenza
💊 asses stridor, 💧🥐 intake
💊 mild-mid ➡️ oral pred
💊 severe ➡️ neb adrenaline
#MedTwitter
#MedEd
#FOAMed
0
11
78
Familial hypercholesterolemia
🧬 Defect in gene affecting 👉🏼 LDLR, APOB, or PCSK9
🌎 heterozygous FH - 1/300 👤
🌎 homozygous FH - 1/300,000 👤
Diagnosis 👉🏼 Dutch lipid score 🧮
🔹Family history - LDL, prem CVD
🔸Clinical history - prem ASCVD
🔹Physical exam - see 📸
1
17
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@BrownHospMed
Calciphylaxis
skin ischemia & necrosis ⏩ can occur in 👥 with ESRD
Cause 👉🏼 ⬇️ arteriolar🩸flow due to calcification, fibrosis & thrombus formation primarily involving the dermo-hypodermic arterioles
📝 ⬆️⬆️ painful rash
🔑 Rx the wound + Rx cause (dialysis)
#MedTwitter
1
8
75
Ways to diagnose HFpEF ?
🫀 H2FPEF
🫀 HFA-PEFF
🔑 Both are useful, but neither is perfect
#MedTwitter
#CardioTwitter
#ACC24
2
14
73
@BrownHospMed
@IhabFathiSulima
Raccoon eyes (periorbital eccyhmosis)
Suggestive of
➡️ basilar skull fracture
➡️ anterior/middle fossa facial fract
🔑 can take 1-3 days to develop
Other 🪧 to 👀 for
👉🏼 mastoid ecchymosis
👉🏼 clear rhin/otorrhoea
👉🏼 haemotympanum
🩻 CT/MRI
🩹 ABC’s
#MedTwitter
#MedEd
0
15
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📚 Ezetimibe | The ABCs of ASCVD 📚
🔬inhibits absorption of chol in the small intestine, resulting in 👇🏼
⬇️ delivery of chol to the liver
⬇️ of hepatic chol stores, causing
⬆️ synthesis of LDL receptors &
⬇️ serum LDL
💊 Ezetimibe 👉🏼 ⤵️ LDL by 15-20%
💊 EZE + ⬆️ dose
1
16
70
Timeline of completed & ongoing LDL cholesterol lowering CV outcomes trials
📚 The data is overwhelming
#Cardiotwitter
#MedTwitter
#ACC2024
#FOAMed
#MedEd
#cholesterol
@Drlipid
@ProfSNicholls
5
31
73
@BrownJHM
Vitamin b12 deficiency 🥚 🥩
🔪 Gastrectomy, bariatric surgery & gastritis causes 👇🏼
🥚 ⤵️ gastric acid & pepsin 👉🏼 which results in impaired liberation of vitamin B12 from food proteins
🥚 ⤵️ in intrinsic factor 👉🏼 impairs vitamin B12 absorption
💉 immediate then lifelong
1
8
71
No statin❓No worries ‼️
At
#ESCCongress
we were reminded of a number of agents to get that
#LDL
⬇️⬇️ in 👤 with/without statin 🙅♂️
❤️ Bempedoic acid (CLEAR)
❤️ evolocumab/alirocumab (FOURIER, ODYSSEY)
❤️ Inclisiran (ORION)
🚨 obicetrapib, evinacumab, oral PCSK9i on the 🌅
4
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69
#EASCongress2024
in review 🎥
What impact does Lp(a) have on CV risk?
Can’t wait to see the CV outcomes of these clinical trials 👇🏼
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
2
12
71
@BrownHospMed
HELP syndrome
⏩ hemolysis (microangiopathic 🩸 smear), ⬆️ LFTs, ⬇️platelet count
0.1-1% of🤰
Treatment
👉🏼 stabilise 👤
👉🏼 Rx HTN
👉🏼 Rx hepatic bleeding
👉🏼 Mg - ⬇️ seizures
👉🏼 antenatal steroids
👉🏼 🤔 ⏰ delivery
#MedTwitter
#MedED
Poster ➡️
@pandoraspilman
1
5
66
@BrownHospMed
See-saw nystagmus
↪️ As one 👁 goes up, the other descends. The elevating 👁 intorts While the descending eye extorts
Causes
👉🏼 parasellar mass (pituitary adenoma
👉🏼 vascular disease (lat medul infarct)
👉🏼 head trauma
👉🏼 visual disorder
👉🏼 congenital
#MedTwitter
#MedEd
0
5
64
Doing an ECG Masterclass session for our
@RACGP
GP registrars early next month
Throw me your ‘Hacks’ or suggested content below! 👇🏼
#MedTwitter
#CardioTwitter
#ECG
@SABOURETCardio
@DrJasonAndrade
0
21
66
What do we do with SGLT2i when the eGFR goes south of 25❓
🚨 keep it going ‼️
Subgroup analysis of DAPA-HF & DELIVER with eGFR < 25 showed that dapagliflozin
👉🏼 ⬇️ rates of CV outcomes
👉🏼 safe ✅ when compared w placebo
#ESCCongress
#CardioTwitter
#MedTwitter
🔗
0
24
64
@BrownHospMed
Osteonecrosis of the jaw (ONJ)
Mechanical failure if the bone ⏩ damage to vasculature/bone marrow
Risk factors
🦷 direct trauma
🦷 💊- steroids, bisphosphonate (BP)
🦷 dx - sickle cell, SLE, gaucher
🦷 radiation
🔑 perform all major 🦷 work prior to BP
#MedTwitter
#MedEd
1
5
62
‘Nature doesn’t care how you reduce
#LDL
’
@ProfKausikRay
Much like in diabetes we need to move towards regular 📝 of a combination of lipid lowering therapies 💊 💉
This isn’t someone else’s problem, not the interventionist, not general cardiology, not the GP 🙈
This is on
1
16
61
@BrownHospMed
@DrCindyCooper
Schmorl's nodes
🦴 represents herniation of the nucleus pulposus into the adjacent end plate
🦴 seen in 20% spine MRI in 👥 🚫 back pain
#MedTwitter
#MedEd
#FOAMed
Pic: necksolutions
2
7
59
@BrownHospMed
@chrismuhr
Stress cardiomyopathy (takotsubo cardiomyopathy)
1️⃣ transient regional systolic dysfunction (principally LV),
2️⃣ mimics myocardial infarction
3️⃣🚫 evidence of obstructive CAD
⁉️ causes
👉🏼 catecholamine ⬆️
👉🏼 microvascular dysfunction
👉🏼multivessel coronary art spasm
#MedEd
0
9
62
@DrPharmDMDTh
@TA_pharmacy
Traditionally was used for prophylaxis of altitude sickness, more recently used in it the IV form for the treatment of decongestion in acute heart failure 👇🏼
and in my humble opinion, significantly under-utilised 😞
0
6
58
@BrownHospMed
Aortic dissection
⏩ tear in the aortic intima, 65% originate in the ascending aorta
3/100,000 👤yrs, 🏔 60-80yo
Risk factors ➡️ HTN, genetic (marfan), pre existing aneurysm, bicuspid AV
📝 severe/tearing posterior chest or back pain
🩹 SURGERY!!!
#MedTwitter
#MedEd
1
7
57
@BrownHospMed
Cold induced acrocyanosis
Cause 👆🏼 Cold agglutinins
IgM antibodies against RBC active at 🌡 ⬇️ normal body temp
cause ➡️ RBC agglutination & extravascular hemolysis with anaemia
🔬 evidence of haemolysis + positive Coombs for C3d only + Cold agglutinin titer of ≥64 at 4°C
0
3
59
45yo African male present for medical
BP 220/130, PR 80, BMI 40
🩺 grade III systolic murmur over aorta, displaced apex, right sided carotid pulsation, bilateral peripheral oedema
ECG 👇🏼
Next step⁉️
#MedTwitter
#CardioTwitter
#fridayspecial
#MedEd
#FOAMed
@BrownJHM
18
11
55
❤️ Calculating ASCVD risk ❤️
Current guidelines refer to LDL 🎯
BUT… does it tell the whole story 🧐
Best tests 👉🏼 to asses ASCVD risk
🥇 ApoB
🥈 Non HDL
🥉 LDL
#MedTwitter
#MedEd
#CardioTwitter
#FOAMed
#lipids
#cholesterol
3
18
58
💔 Heart failure pathophysiology 💔
A ⤵️ in cardiac output 👉🏼 triggers ‘adaptive’ changes which ultimately 🔄 become ‘maladaptive’ ☠️ 🏥
Adaptive 🥅 👉🏼 maintain sys pressure
🔸vasoconstriction
🔹myocardial contractility ⬆️
🔸heart rate ⬆️
🔹expansion of extra cellular fluid
1
8
56
Out with the old ❌
🔸 Microalbuminuria
🔸 Macroalbuminuria
& in with the new ‼️
🔹 Moderately increased albuminuria*
🔹 Severely increased albuminuria**
* ACR 3.4-34 mg/mol
** ACR > 34 mg/mol
#MedTwitter
#MedEd
#CardioTwitter
#FOAMed
1
23
58
@BrownHospMed
Wilson disease
Autosomal recessive 🧬 disorder of copper metabolism, affects 1/30,000
Often diagnosed 5-35yo w
👉🏼 hepatic - Acute/chronic liver dx
👉🏼 neuro - dysarthria, movement disorders
👉🏼 psych - depression (30%), behavioural change, irritability
#MedTwitter
#MedEd
0
7
57
@BrownHospMed
Rhinophyma
3 reasons to get more aggressive with you rosacea management
1️⃣ rhinophyma
2️⃣ blepharitis
3️⃣ scarring
⚠️ avoid triggers ➡️ 🍷 ☀️ 🌶
💊 topical ➡️ doxycycline ➡️ oral isotretinoin
#MedTwitter
#MedEd
#GPtips
0
10
56
@BrownJHM
Lyme disease
Spirochetal infection (Borrelia species) 🔄 by the bite of infected Ixodes ricinus complex ticks
Treatment 👇🏼
🦠 Early localized - 10/7 doxycycline
🦠 Early disseminated - consider IV doxy
🦠 Late disease - re evaluate 💊 & 🩺
#MedTwitter
#MedEd
5
10
55
@BrownHospMed
@Radiopaedia
Gastric bezoars ➡️ accumulation of foreign ingested material
Classified by composition
👉🏼 Phytobezoars- vegetable matter
👉🏼 Trichobezoar- hair
👉🏼 Pharmacobezoars- medication
Symptoms ➡️ abdo pain, nausea, 🤮 early satiety, anorexia
⚠️ GIT🩸 due to concurrent gastric ulcers
0
2
55
@BrownHospMed
@Radiopaedia
Meningioma
1/3 of all primary 🧠 & spinal rumours,
Median age 65yo ⏫ in women
Risk factors
👉🏼 ☢️ therapeutic & incidental
👉🏼 🧬 ie neurofibromtosis t2
👉🏼 hormonal factors- oestrogen/prog
Can arise anywhere from the dura, tend to be slow growing
#MedTwitter
#MedEd
1
6
53
🫀 Residual CV risk 🫀
The greatest CV risk ⤵️ in statin trials? 👉🏼 45%
🚨 SO, the majority of clinical events that were going to occur, would STILL occur, even if we treat 👥 w statins 🤯
💡Combination lipid lowering therapies
💊 Ezetimibe, BPA 💉PCSK9i, Inclisiran
4
21
52
#EASCongress2024
in review 🎥
Is ultra low LDL dangerous ⁉️
FOURIER-OLE
👉🏼 no meaningful ⬆️ in diabetes, cancer, cataract, hemorrhagic stroke
🔑 LDL 👉🏼 lower, earlier, longer
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
1
20
56
@BrownHospMed
@drnhassanpour
That’s one freaky 👻 left atrial mass!!
Likely myxoma or thrombus
0
3
52
#EASCongress2024
in review 🎥
We’re good at managing 🫀disease right ⁉️
Compared to HTN & Diabetes, ASCVD is
Under diagnosed
Under treated
🚫 meeting targets
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
1
29
54
Aspirin was associated with a 46% ⤵️ in CHD events in 👤with a lipoprotein(a) >50 mg/dL & no prior CVD
Is aspirin back on the table for primary prevention ⁉️
@hsbhatia
@CMichaelGibson
@maciejbanach
@ProfKausikRay
@ErinMichos
@SABOURETCardio
@GoggleDocs
🔗
3
9
53
@BrownHospMed
Open globe rupture / Penetrating eye injury
⚠️ avoid - eye manipulation, topical solutions, causing ⬆️ intra ocular pressure
👉🏼 eye shield
👉🏼bed rest
👉🏼anti emetic
👉🏼 CT - non contrast
‼️ urgent opthal rv, abx coverage, primary closure
#MedTwitter
0
1
51
What are our Rx targets in ASCVD ⁉️
Risk | ApoB** | non-HDL-C*| LDL-C*
Ext <50 <1.8 <1.0
VH <65 <2.2 <1.4
H <80 <2.6 <1.8
M <100 <3.4 <2.6
0
13
52
@DanielAndrewsMP
If it’s a matter of convenience as mentioned 👆🏼 wouldn’t it be MORE convenient to have multiple scripts dispensed at the same time?
That way you get the safety of 6 monthly review at your
#GP
, without the hassle of monthly trips to the chemist!?
@DanielAndrewsMP
7
15
50
@BrownHospMed
@grepmeded
Chorea
hyperkinetic movement disorder with
📍unpredictable contractions
📍mostly limbs, less commonly face & trunk
📍flow through the body
📍 mild cases - 👀 like fidgetiness
Divided into
Hereditary (ie Huntington’s)
Acquired (vascular, endocrine…)
#MedTwitter
#MedEd
0
7
49
@BrownHospMed
Trachoma
Chronic keratoconjunctivitis caused by recurrent infection w Chlamydia trachomatis
transmitted in areas of poor hygiene 👁 ➡️ ✋
two phases
👁 active trachoma (conjunctivitis)
👁 cicatricial disease (conjun scarring)
🔑 leading cause of blindness 🌎 wide
#MedEd
1
5
50
Heart failure 🔥 takes
#CSANZ2023
❤️ STRONG-HF - early 💊💊💊💊 initiation before discharge from 🏥
❤️ CHAMP-HF - 💊 works best when prescribed/taken, uptitrate ‼️
❤️ Don’t forget non GDMT options 👉🏼 weight & 🍻 ⬇️, 🏃♂️ ⬆️ & control BP
❤️ HFmrEF don’t forget the middle
1
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49
Lifetime exposure to ⬆️ LDL-C is a causal & cumulative risk factor for ASCVD
❤️ Early (<40yo)
❤️ Even modest (35% LDL-C ⤵️)
Leads 👉🏼 ⬇️⬇️ cumulative lifetime incidence of MACE
#MedTwitter
#CardioTwitter
#MedEd
#FOAMed
@ProfKausikRay
1
12
47
#EASCongress2024
in review 🎥
The appearance of CAC is a late process in the course of atherosclerosis
Calcified Plaque = secondary prevention
@society_eas
@EASCongress
#medtwitter
#cardiotwitter
7
12
48
📚 SELECT trial 📚
Semaglutide 2.4mg vs placebo in overweight (BMI>27) 👥 with existing ASCVD 🚫 diabetes
17,000 👤 f/u for ~40 months
❤️ 20% ⤵️ in 3 point MACE (CV ☠️, non fatal MI/stroke
❤️ favourable signals for heart failure & all cause ☠️
❓Is it the weight ⬇️ or
2
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47
🫀 ASCVD paradigm shift 🫀
If we wait for the MI, the 🚢 has sailed
In fact 🙋🏽it left 20 years earlier…
🥅 should be early identification of ⬆️ risk 👥 followed by 👉🏼aggressive LDL ⤵️
How do you do this?
❤️ Identify risk factors 📝
❤️ upfront combo lipid ⤵️ therapy
❤️
0
14
46
@BrownHospMed
Strychnine poisoning
Strychnine's toxicity antagonizes inhibitory tone in motor neurons of the spinal cord's neural horn ⏩ powerful & uncontrollable 💪 contraction
💊 benzo’s ➡️ control 💪 contraction
☠️ can occur from respiratory compromise
#MedTwitter
#MedEd
#FOAMed
0
8
44
@BrownHospMed
Osteogenesis imperfecta (OI)
OI ‘brittle bone disease’ ⏩ inherited connective tissue disorder
1/20,000 👤
Consider in 👥 with 🦴 fragility +
👉🏼⬇️ stature
👉🏼scoliosis
👉🏼basilar skull deformity
👉🏼blue sclera
👉🏼opalescent 🦷
👉🏼lax ligaments
👉🏼bruising
#MedTwitter
1
8
44
@BrownHospMed
@Radiopaedia
Schatzki ring
Oesophageal rings & webs
👉🏼thin structures that partially occlude the oesophageal lumen
👉🏼Typically occur in the distal oesophagus
🩻 barium swallow
🩹 gastroscope +/- dilatation
💊 Recurrent OE rings or OE ring with reflux 🟰indefinite PPI
#MedTwitter
0
11
46